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Occasional Papers

  • The POLICY Project conducted assessments of adolescent and youth reproductive health in 13 countries in the Asia and Near East (ANE) region that represent diverse population sizes and geographic, cultural, and socioeconomic settings. The countries include Egypt, Jordan, Morocco, and Yemen in the Near East; Bangladesh, India, Nepal, Pakistan, and Sri Lanka in South Asia; and Cambodia, Indonesia, the Philippines, and Vietnam in Southeast Asia. In 2000, the 13 countries accounted for a total of 354 million young people ages 15 to 24 years. The purpose of the assessments was to highlight the reproductive health status of adolescents and youth in each country within the context of the lives of young males and females.
  • This paper suggests ways in which policy analysis guided by human capital theory might inform national debates concerning the implementation of programs aimed at achieving the reproductive health priorities set forth in the ICPD Programme of Action. Linking reproductive health policies and programs to their likely human capital impacts shows policymakers that, in addition to helping meet individuals' basic human rights to reproductive health, investments in reproductive health services benefit the public interest by increasing the productive potential of individuals and their immediate social unit—the family or household. Moreover, increases in productive potential at the individual, family, or household level cumulate to increases in productive potential at the societal level. The economic rationale and supporting evidence provided by a human capital approach to the promotion of reproductive health may help strengthen the case for adopting policies and financing programs that will make the right to reproductive health services and information a reality. To gain a better understanding of how to design reproductive health policies and programs to promote human capital development, this paper relies on a conceptual framework built in three stages. The first stage presents an overview of how reproductive health contributes to development both directly through human capital accumulation and indirectly through the loosening of resource constraints resulting from reduced population growth. The second stage develops more fully the mechanisms through which reproductive health augments human capital. Finally, the third stage synthesizes the concepts and linkages presented in the first two stages and shows how the human capital approach might be relevant to reproductive health and program development. The paper contains a detailed list of illustrative impacts of selected reproductive health interventions on human capital formation as well as an extensive bibliography of research documenting those impacts.
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  • The 1994 ICPD intensified the worldwide focus on reproductive health policies and programs. Officials in many countries have worked to adopt the recommendations in the ICPD Programme of Action and to shift their population policies and programs from an emphasis on achieving demographic targets for reduced population growth to a focus on improving the reproductive health of their population. This paper presents information from case studies carried out in Bangladesh, India, Nepal, Jordan, Ghana, Senegal, Jamaica, and Peru to assess each nation's process and progress in moving toward a reproductive health focus. The case studies show that within their unique social, cultural, and programmatic contexts, the eight countries have made significant progress in placing reproductive health on the national health agenda. All countries have adopted the ICPD definition of reproductive health either entirely or in part. Policy dialogue has occurred at the highest levels in all countries. The countries have also achieved considerable progress in broadening participation in reproductive health policymaking. Bangladesh, Senegal, and Ghana have been particularly effective in involving NGOs and civil society organizations in policy and program development. In some of the other countries, however, the level of participation and political support for reproductive health may not be sufficient to advance easily to the next crucial stage of implementation. The case studies indicate almost uniformly that countries are grappling with the issues of setting priorities, financing, and implementing reproductive health interventions. Bangladesh has made the greatest progress in these areas while India, Nepal, Ghana, Senegal, Jamaica, and Peru are beginning to take steps toward implementation of reproductive health activities. Jordan continues to focus primarily on family planning. Several challenges face these countries as they continue to implement reproductive heath programs. These challenges include improving knowledge and support of reproductive health programs among stakeholders; planning for integration and decentralized services; strengthening human resources; improving quality of care; addressing legal, regulatory, and social issues; clarifying the role of donors; and maintaining a long-term perspective regarding the implementation of the ICPD agenda. Despite many encouraging signs, limited progress has been achieved in actually implementing the Programme of Action; this finding is neither surprising nor unexpected. It took more than a generation to achieve the widespread adoption and implementation of family planning programs worldwide, and that task is far from complete. The key to continuing progress lies in setting priorities, developing budgets, phasing-in improvements, and crafting strategies for implementation of reproductive health interventions.
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  • AIDS has presented a major challenge to African societies during the last two decades. Governments throughout the region have struggled to develop effective policies and programs to address the epidemic. This report presents case studies of the policy process in nine Anglophone African countries. Each country has employed a unique approach to policy development; the results are equally diverse. This report describes some of the country experiences and highlights areas of similarity and difference as well as major problems addressed by Anglophone African countries. The information has been distilled into a framework that captures key elements of the policymaking process. The major components of the framework are as follows: Problem identification and need recognition. Countries have passed through several stages in their response to the AIDS epidemic, including medical response, public health response, multisectoral response, and focused prevention and treatment. During the early phases, countries saw little need for a comprehensive AIDS policy. However, the need for a policy response grew as countries adopted multisectoral approaches to the epidemic and the broad impacts of AIDS on human rights, economic growth, society, and families emerged. Information collection. Once a decision to develop a policy is made, the next step usually is to obtain expert opinion—through consultant reports, interviews, or workshops. Drafting. Drafting is usually the task of small working committees. Some countries drafted policies quickly with a minimum of outside participation while others relied on a number of drafting committees that sought input and consensus from a range of interests. Review. In some cases, draft policies were debated widely and reviewed by thousands of people as a result of special regional meetings and dissemination efforts. In other cases, little outside review took place. As a consequence, policies often languished, with no champions pushing for review and approval. Approval. National AIDS policies have been approved at one of three levels: the minister of health, the cabinet, or Parliament. Implementation. Some policies have been implemented through operational or strategic plans or through the establishment of committees to develop operational guidelines. In many cases, elements of the policy can be implemented even before the full policy is adopted. Interest groups may be encouraged to take the lead in disseminating and implementing parts of the policy that are of particular interest to them. Most policies contain some components that can be implemented immediately though administrative actions; other components require efforts to develop specific legislation and to obtain funding. Each country policy addresses a large number of specific issues. Despite several cultural, social, and legal differences among the countries studied, the issues surrounding key policy topics show many similarities. The following are among the topics that were most difficult to resolve: HIV counseling and testing; pre-employment testing; orphans; AIDS education in schools; condom advertising; mandatory condom use in brothels; condom distribution in prisons; willful transmission of HIV; and HIV and abortion. In some instances when it was difficult to achieve consensus, policymakers simply eliminated issues from policy consideration. For example, most policies do not address willful transmission of HIV. In other cases, vague wording requires the issue to be addressed in national policy, with the exact meaning left to interpretation through implementation guidelines. The key lessons that have emerged from the case studies are summarized below. Identifying AIDS as a problem does not translate into recognition of the need for a comprehensive AIDS policy. The need for a comprehensive policy may become apparent only when the epidemic becomes so severe that a large portion of the population is affected or when the advocacy efforts of specific groups convince decision makers of the importance of a policy response. There are many approaches to drafting and review. Some countries rely on a high level of participation. Although greater participation lengthens the time required for drafting and review, it builds momentum for the policy and often shortens the time required for approval. As a result, highly participatory approaches may actually require less time for policy development than policies drafted rapidly by a small group of experts who then struggle for years to gain approval. The most participatory processes have produced the broadest policies covering a wide range of key issues. Such policies, it is expected, will prove to be the most effective, but the outcome remains to be demonstrated. Once approved, policies can be implemented in many ways. Some aspects of a policy (such as approval of condom advertising) may be implemented directly, in some cases even before the policy is formally approved. Other policy issues can be implemented only through enabling legislation, with the development of guidelines, or as part of a strategic plan. Countries may lack the resources to implement all facets of a policy at once. Interest groups may need to take the lead in advocating for the implementation of specific portions of the policy that most interest them.
  • The countries that agreed to the ICPD Programme of Action face a tremendous challenge in its implementation. Additional funds will help; however, in the face of scarce resources, countries also need to find ways to make existing resources go further. As countries strive to implement the reproductive health initiatives to which they agreed at Cairo, many are also undertaking health sector reform, a set of sweeping initiatives that affects all components of health, including decentralizing the management and provision of care, concentrating resources on cost-effective interventions (often through minimum or essential services packages), improving the performance of providers, expanding the role of the private sector, shifting the function of central ministries of health and improving their regulatory capacity, broadening financing, and shifting donor financing to support sector-wide health programs rather than vertical programs, such as family planning. Reproductive health initiatives and health sector reform share the goals of equity and quality. The question of interest to those working in reproductive health is whether the reform measures aimed at increasing efficiency will be sufficient to ensure universal access to high-quality reproductive health services by 2015, as outlined in the ICPD Programme of Action. This paper reviews evidence that addresses the question of the complementarity of reproductive health initiatives and health sector reform. Decentralization: While decentralization is sound in theory, it is not easy to implement in practice and may take as long as 10 to 20 years. Thus, the effect of decentralization on health care, including reproductive health care, is unclear. While some experiences with decentralization have been favorable, central governments have often transferred responsibility to local administrative levels without planning properly for implementation and without allocating adequate resources. In fact, existing human and technical resources are often underdeveloped at the local level. Decentralization may not promote equity, at least not in the short term. Local areas may have variable access to resources; thus, residents of poorer areas may receive less care than residents of wealthier areas. The need is clear for further analysis of health and equity outcomes related to decentralized management and provision of reproductive health. Integration: The ICPD promoted integration of services to ensure greater responsiveness to meeting clients' reproductive health needs. In the context of health sector reform, integration is more broadly defined; to reformers, integration of reproductive health as envisioned at the ICPD is just another vertical program. Integration is best suited for services targeted to a similar clientele, for example, family planning linked with postpartum services. A few examples of successful integration of reproductive health services can be found, most notably in programs of nongovernmental organizations (NGOs). Since ICPD, family planning and STD/HIV/AIDS are the two main reproductive health components that have undergone integration, particularly in Africa. However, many family planning clinics are not equipped to offer services for the detection and treatment of sexually transmitted diseases (STDs), and staff members are not properly trained. Essential Services Packages: Under health sector reform, more and more countries are implementing minimum or essential care packages of cost-effective interventions designed to reduce the burden of disease among the population. Essential services packages developed to date have generally included reproductive health components. Making Better Use of Existing Program Capacity: More efficient, high-quality care could attract additional clients for reproductive health services and thus save money. Without improvements in quality, however, utilization of reproductive health services may suffer, particularly if cost-recovery schemes are introduced. Further evaluation is required to determine whether improvements in quality (as distinct from the availability of drugs) will lead to increased demand for services, which, in turn, can translate into increased revenue. Evaluation of operational policies, including those affecting the provision of reproductive health services, often uncovers procedures that involve unnecessary and burdensome steps. Streamlining operational policies could make services more efficient. In addition, medical and other service barriers often inflate the cost of services. Many countries are updating their service delivery guidelines to reflect the recent international consensus on more streamlined but medically safe protocols for contraceptive and reproductive care. Role of Public and Private Providers: Health sector reform promotes separation of the financing of services from the provision of services. In theory, governments should delegate service provision to organizations closer to communities, including local governments and the private sector, if one exists. Family planning programs have had some success in encouraging wider participation of the private and commercial sectors in service provision. Ministries of health should focus on sector management by developing legal and regulatory frameworks that direct the actions of both local governments and private providers and promote preventive care. Many countries regulate the behavior of private health providers and the distribution of drugs; enforcement of regulations, however, is another matter. If governments remain in the business of service delivery, including reproductive health care, they should ensure a "level playing field" by providing similar subsidies and incentives to the private sector and NGOs as they provide for public sector services. Broadening Health Care Financing: Results of initiatives in cost recovery, particularly the use of user fees, have been mixed, even for family planning. Some studies show that small increases in user fees do not affect health care utilization rates, particularly if quality of care (and drug availability) is improved. Other studies, however, have shown that user fees have adversely affected women and children, forcing them to forgo needed health care. Some countries are seeking to promote equity in health care through prepayment schemes and risk-sharing mechanisms. Sector-Wide Assistance Programs: Donors and international financial institutions are testing various sector-wide assistance programs (SWAPs) to support health sector reform, in order to move from a narrow project focus to a sectoral focus and to help establish joint instead of donor-driven priorities. As with other aspects of health sector reform, SWAPs are not easy to implement and tend to function best in politically and economically stable environments, conditions absent in many developing countries. Discussion: Health sector reform is complex and to be successful, requires time, political commitment, an initial investment of resources, and a favorable policy environment. Without proper planning and implementation, reform is unlikely to be successful and may even waste resources. Within the context of health sector reform, several challenges exist in the design and implementation of reproductive health programs, including setting priorities, costing integrated services, determining new approaches for financing and providing services, and redefining the roles of central maternal and child health (MCH) and family planning divisions. With few current examples of successful reform positively affecting reproductive health programs, it is too soon to say whether health sector reform will promote efficient, effective, and equitable reproductive health care delivery, or whether reforms will result in the neglect of reproductive health in the face of other pressing health care issues. It is imperative that reform processes, including the reform of reproductive health services, be monitored, documented, and evaluated. Equity and access issues often get lost in the details of implementing programs to increase efficiency. Those involved in reproductive health programs, including client advocates at the local, national, and international levels, need to be "at the table" when decisions on reforms are made. In addition to promoting more efficient programs and services for reproductive health, those involved in decision making must ensure that equity and access to high-quality services are primary goals of reform programs if the ICPD Programme of Action is to be achieved.
  • Given the scarcity of resources available to implement the ICPD Programme of Action, this paper assesses effective interventions and their cost for three main components of reproductive health: family planning, safe motherhood, and STD/HIV/AIDS prevention and treatment. The paper also suggests some of the economic criteria governments can use to determine the role of the public sector in providing and/or financing reproductive health services. Family Planning Ensuring that individuals have access to a range of family planning methods and related information can help reduce unwanted pregnancy and thus maternal mortality. Promotion of condoms can help prevent the spread of sexually transmitted diseases (STDs). Family planning is most effectively provided through a range of channels, including clinics, community-based distribution, social marketing programs, and the private sector. Comparing the costs of service delivery approaches is problematic in that each channel tends to serve different clients. Contraceptive methods involve a range of costs; IUDs and sterilization tend to be the least expensive methods per couple-year of protection (CYP), although both have high "up-front" costs. The pill tends to be the least expensive supply method. Family planning, however, is most effective if a range of methods is available so that clients can select a method that matches their needs. One solution to the scarcity of resources may be for governments to subsidize all contraceptive methods for the poor and only lower cost methods for other groups and to require users to pay for the incremental cost of more expensive methods. Safe Motherhood An estimated 40 percent of pregnant women develop complications that require the assistance of a trained provider; 15 percent require medical care to avoid death or disability. Good prenatal care is important; given current screening tools, however, it is not prudent to spend resources on screening as the sole mechanism for predicting women's risk of developing complications. Instead, prenatal care should, among other activities, educate all women about danger signs, possible complications, and where to seek help. Micronutrient supplementation, including vitamin A, iron, folic acid, zinc, and calcium, show promising results in helping to improve pregnancy outcomes and reduce maternal mortality. The most crucial interventions for safe motherhood are to ensure that a health worker with midwifery skills is present at every birth, that transportation is available in case of emergency, and that quality and timely emergency care is available at the referral level. It is not only important that adequate access to emergency care be available but that women, families, and the community have confidence in the referral system and higher levels of care. Communities use emergency obstetric care services that they know to be functioning well. Nearly two-thirds of maternal deaths occur in the postpartum period; therefore, the World Health Organization (WHO) recommends that, if possible, community health workers visit women not attended at birth within 24 hours of delivery and again within three days. In many low-income countries, effective and safe postabortion care can significantly reduce maternal mortality rates by as much as one-fifth. Furthermore, such care can reduce overall health care costs as it is not uncommon for most beds in emergency gynecology wards to be occupied by women suffering from abortion complications, the treatment of which can cost five times the annual per capita health budget. The high cost of postabortion care can be reduced by switching from sharp curettage to manual vacuum aspiration (a safer and less expensive method), establishing referral systems and links with family planning and other reproductive health services, and preventing abortion through family planning. Substantial additional resources may not be required to improve emergency obstetric care. Most of the cost of providing such care is already paid through the maintenance of hospitals, health centers, and health care staff. Instead of creating new medical facilities and hiring new staff, emergency obstetric care can be improved by renovating existing facilities and training staff, including midwives and general practice physicians. STD/HIV/AIDS The best combination of STD/HIV/AIDS activities and services is general information and education, improved health-seeking behavior for STD treatment, wide access to condoms, and STD services with focused attention to core transmitters. WHO advocates the use of the syndromic management approach to managing STDs. This approach has limitations, however. It functions well for men with symptomatic urethral discharge and for women with genital ulcer disease, but not for women with vaginal discharge. The women who receive medical attention are often overtreated with drugs. More work is needed to develop cost-effective approaches to screening and treating reproductive tract infections. There are promising treatments to prevent mother-to-child transmission of HIV. Nevirapine has recently been shown to reduce transmission dramatically from mothers to infants at a fraction of the cost of treatment with Zidovudine (AZT) (US$4 compared with US$100), although universal HIV screening is not part of prenatal care in many developing countries and would raise the cost of prevention. Maternal syphilis diagnosis and treatment is also cost-effective. Blood screening for HIV/AIDS in high-prevalence areas has proven cost-effective. HAART (highly active antiretroviral therapy) for HIV/AIDS-infected individuals presently costs about US$8,000 to US$10,000 per person. Governments and donors will not be able to cover the cost of such treatment. In many developing countries, less than 1 percent of people living with AIDS will ever be treated, even if all reproductive health donor funds were allocated for that purpose. Information, Education, and Communication (IEC) and Behavior Change Communication (BCC) IEC and BCC have the potential to be highly effective in helping promote good reproductive health. Properly executed, IEC and BCC can encourage individuals to take preventive measures to protect their reproductive health as well as seek appropriate reproductive health services. IEC and BCC activities warrant government support if they convey appropriate messages to target audiences and are associated with services already in place. In the absence of these conditions, IEC and BCC activities are not only ineffective but also give rise to unsatisfied demand. Some Economic Criteria for Governments to Use in Deciding Whether They Will Provide and/or Fund Services From an economic standpoint, governments should intervene in reproductive health care if intervention increases efficiency and productivity in the health sector. Governments should redistribute resources to ensure equitable access to reproductive health services by all individuals. Governments should subsidize activities with large external or social benefits that go beyond the individual. Governments must regulate all sectors to ensure high-quality care and equitable access to reproductive health services. Government services are rarely more efficient than private sector services. Governments should encourage development of the private sector and provide subsidies to the poor so that they can afford needed services. To encourage development of the private sector, governments should provide similar subsidies to all providers (rather than only to government providers) either directly or through income transfers to individuals so that consumers can choose their own provider, thereby spurring competition and, it is hoped, better quality services for all. Governments should not provide subsidies to those able to pay for reproductive health services. Growing evidence suggests that some users, particularly in middle-income countries, can pay for family planning, maternal health, and postabortion care services. After reviewing implementation of the ICPD Programme of Action, the international community has reached consensus that certain basic services should be provided at the primary health care level and subsidized for those who cannot afford to pay for them. In low-income countries, where most individuals are too poor to pay for services, evidence suggests that it would be desirable for governments to subsidize family planning services, prenatal care that includes physical examinations, postpartum provision of family planning information and services, and postabortion services. In addition, skilled attendance at delivery and a functioning referral system and emergency care are essential to reduce maternal mortality. As for STD/HIV/AIDS, resources should be focused on prevention activities such as promotion and distribution of condoms to prevent STDs, STD treatment for high-risk groups, improved health-seeking behavior for STD treatment, and maternal syphilis treatment. Where HIV screening is part of prenatal care, provision of Nevirapine or AZT for infants of HIV-positive mothers may be feasible. While governments should strive to ensure that their citizens have access to reproductive health services as agreed at the ICPD and ICPD+5, policymakers will have to begin with a narrower set of interventions consistent with current resource and capacity levels and decide how to phase in additional services as resources become available. It is clear that a substantial amount of work on costing interventions and services and measuring their effectiveness is necessary before we can say, with greater assurance, what combination of services works at the most reasonable cost. Data collected in one country or service delivery setting may not apply in others, and further research is needed. Still, while the data are not comprehensive or perfect, policymakers and others can use the information at hand to help make difficult decisions, especially on what to provide to low-income clients through public sector facilities or financing.
  • 1998, le Réseau de recherche en santé reproductive
  • The 1994 Cairo International Conference on Population and Development (ICPD) increased worldwide focus on reproductive health. Many countries have been working to revise their reproductive health policies in accordance with the ICPD Programme of Action. In 1998, the Network for Reproductive Health Research in Africa (RESAR), with support from the POLICY Project, conducted case studies in five Francophone African countries-Benin, Burkina Faso, Cameroon, Côte d'Ivoire, and Mali-to examine field experiences in formulating and implementing reproductive health policies. Findings were based on in-depth interviews with key informants active in the reproductive health field in their respective countries. Because the five countries are located in the same region, they exhibit many similarities, yet each differs slightly in the challenges it faces and the approaches it takes to confront them. In general, the five countries have made considerable progress in integrating the concept of reproductive health into policies and programs, although more needs to be done to disseminate new policies and implement effective programs. While some aspects of reproductive health generate opposition, particularly programs for youth and programs against female genital cutting, overall support for reproductive health has increased in recent years. Governments are allowing nongovernmental organizations (NGOs) to participate in policy formulation, and most countries are devoting more internal resources to reproductive health. Though these changes are encouraging, continued resistance on the part of the public sector to full partnership with NGOs, as well as the varying capabilities of many NGOs, has hindered NGO participation. Moreover, countries are still highly dependent on support from international donors for their funding. Less progress has been made in program implementation than in policy formulation. Some concrete changes are apparent, but the task of converting the concept of reproductive health into a reality in the field is sure to be a long, slow process. Poverty and underdevelopment in the region are major constraints to reproductive health programs; consequently, countries must focus their efforts on priority interventions and use their existing resources more efficiently. The case studies also highlight the need to continue efforts to create broad-based support for reproductive health programs, improve coordination among stakeholders, strengthen NGOs so that they can effectively participate in the policy process, and enhance the financial sustainability of programs.
  • Spanish
  • Many countries around the world have made great progress in improving reproductive health programs that now reflect the principles of the 1994 ICPD Programme of Action. Governments and donors have pursued two main routes to improving reproductive heath. First, they have enacted national policies and laws aimed at expanding services and raising the quality of available services. Second, they have implemented a wide range of service projects and demonstrations to show how services can be enhanced and client education improved. Too often, however, national policies and laws are not translated into systemwide programs and improved reproductive health services, especially for the poor. Because these doctrines are necessarily broad and encompassing, they neglect the structures and systems that serve as a bridge between national policies and local programs. Projects and demonstrations are often not replicable because they are not financially sustainable in the long run. More important, they generally do not systematically address the underlying policy constraints in the structures and systems that affect the service delivery environment. This paper focuses on the vast arena between national policies and the point of service delivery, which is the domain of operational policies. Operational policies are the rules, regulations, codes, guidelines, and administrative norms that governments use to translate national laws and policies into programs and services. While national policies provide necessary leadership and guidance, operational policies are the means for implementing those policies. In many cases, program deficiencies, such as a lack of trained service providers and other resources, can be traced to operational policies that are inadequate, inappropriate, or outdated. Poor operational policies result in wastage and inefficiency that pervades every clinic, health post, and hospital and adversely affects health personnel and every client. When drafted or modified appropriately, operational policies can help enhance the quality of reproductive health programs by making more efficient use of existing resources. The paper discusses the nature of operational policies, stresses the important role they play in the continuum from national decrees to local services, and provides a framework for operational policy reform.
  • French
  • The transition to low fertility in much of the developing world is incomplete. To leave it half-finished or to slow its pace would have enormous demographic, programmatic, and foreign assistance implications. Despite considerable progress over the last 35 years, much remains to be done to complete the demographic transition. The world’s population has not stopped growing, and it is growing fastest in the poorest countries. To achieve sustainable development, strong measures by governments and donor organizations to promote fertility decline in developing countries—and to give individuals and couples the means to do so—need to continue for the foreseeable future. This paper reviews the status of the demographic transition worldwide, discusses factors associated with fertility decline, and highlights challenges associated with completing the transition in developing countries. It is intended to help policymakers both here and abroad to better understand the need for continued efforts to reduce fertility and population growth rates, even in the wake of the HIV/AIDS epidemic. A reduction in population growth to sustainable levels is not something that will just occur on its own. Completing the demographic transition requires addressing a number of challenges—and first and foremost is maintaining strong support for family planning programs from governments and donor organizations. Sustaining the demographic transition also requires focused attention on other proximate, or direct, determinants of fertility, such as increasing the age at marriage and reducing abortion. In addition, donors and governments have an important role to play in providing continued support for policies that indirectly affect fertility, such as promoting girls’ education and safe motherhood.