Addressing the Reproductive Health Needs and Rights of Young People since ICPD- The Contribution of UNFPA and IPPF

Publication date: 2003

Egypt Country Evaluation Report Add re s s i ng t he Re p ro d uc t i v e He a l t h N e e d s a nd R i g h t s o f Yo u ng Pe o p l e s i n c e I C P D – T h e C o n t r i b u t i o n o f U N F PA a n d I P P F DFID Department forInternationalDevelopment Addressing the Reproductive Health Needs and Rights of Young People since ICPD: The contribution of UNFPA and IPPF Egypt Country Evaluation Report September 2003 Written by: Tawhida Khalil Juliette Boog Rania Salem For: UNIVERSITY OF HEIDELBERG UNFPA and IPPF Evaluation: Egypt Country Report i CONTENTS Acronyms. . . . ii Analytical Summary . . . .1 Key Findings and Recommendations. . . 9 Introduction . . . . 13 Section 1: The Country Specific Context . . . 15 Section 2: The Strategic Priorities of the Country Programmes. .28 Section 3: Institutional Arrangements. . . 44 Section 4: Enabling Policy Development and Reform. . 54 Section 5: Strengthening Reproductive Health Services. . 57 Section 6: Promoting Reproductive Health Information and Education. .63 Annexes Annex 1: Key persons met and itinerary Annex 2: Stakeholder Workshop: Agenda, Participants, Worksheets and Summary of Conclusions Annex 3: Youth Workshop: Agenda, Participants, Worksheets and Summary of Conclusions Annex 4: Methodology and field instruments Annex 5: UNFPA Youth Focused Projects Annex 6: Aide Memoire (One for each Organisation) Annex 7: Organograms for both UNFPA CO and EFPA/IPPF Egypt Office Annex 8: References Annex 9: Terms of Reference UNFPA and IPPF Evaluation: Egypt Country Report ii ACRONYMS APR Annual Project Report ARH Adolescent Reproductive Health ASCE Social and health status and educational achievement of adolescents in Egypt ASRH Adolescent Sexual and Reproductive Health BCC Behavioural Change Communication CAPMAS Central Agency for Public Mobilisation and Statistics CCA Common Country Assessment CDA Community Development Associations CEDAW Convention for the Elimination of All Forms of Discrimination Against Women CO Country Office CP Country Programme CPA Country Population Assessment CRC Convention for the Rights of the Child CSI Clinical Services Improvement CST Country Support Team DAG Donor Assistance Group DANIDA Danish International Development Association DHS Demographic and Health Survey EDHS Egypt Demographic and Health Survey EFPA Egyptian Family Planning Association EMICS Egypt Multiple Indicator Cluster Survey ESPSRH Egyptian Society for Population Studies and Reproductive Health FGDs Focus Group Discussions FGC Female Genital Cutting FLE Family Life Education FP Family Planning FPA Family Planning Association GOE Government of Egypt HCI Health Care International ICPD International Conference on Population and Development IEC Information, Education and Communication IPPF International Planned Parenthood Federation ILO International Labor Organisation ITRFP Institute for Training and Research in Family Planning JPO Junior Professional Officer KAP Knowledge, Attitudes and Practices MCH Maternal and Child Health MDG Millennium Development Goal MOAg Ministry of Agriculture MOE Ministry of Education MOHP Ministry of Health and Population MOSA Ministry of Social Affairs MOY Ministry of Youth MTR Mid-Term Review MYFF Multi Year Funding Framework NCCM National Council for Childhood and Motherhood NCPD National Centre for Population and Development NCW National Council for Women NPC National Population Council NPRHS National Population and Reproductive Health Strategy PDS Population and Development Strategy UNFPA and IPPF Evaluation: Egypt Country Report iii PHC Primary Health Care POA Programme of Action PopEd Population Education PRM Project Review Meeting PRSD Programme Review and Strategy Development RH Reproductive Health RH&R Reproductive Health and Rights RHWG Reproductive Health Working Group SDP Service Delivery Point SO Strategic Objective SP Strategic Plan SRHR Sexual and Reproductive Health and Rights SRM Sub-programme Review Meeting STIs Sexually Transmitted Infections TFR Total Fertility Rate TOR Terms of Reference TOT Training of Trainers UNAIDS United Nations Programme for AIDS UNDAF United Nations Development Assistance Framework UNFPA United Nations Population Fund UNFPA CO Country Office UNICEF United Nations Children’s Fund USAID United States Agency for International Development WB World Bank WHO World Health Organisation UNFPA and IPPF Evaluation: Egypt Country Report 1 ANALYTICAL SUMMARY Introduction The German Ministry for Economic Cooperation and Development (BMZ), the Danish Ministry of Foreign Affairs, the UK Department for International Development (DFID), the Netherlands Ministry of Foreign Affairs, and the Norwegian Ministry of Foreign Affairs have sponsored an evaluation of the contribution of the United Nations Population Fund (UNFPA) and the International Planned Parenthood Federation (IPPF) to addressing the reproductive rights and health needs of young people in the period since the finalisation of the Programme of Action (POA) developed at the International Conference on Population and Development (ICPD) in 1994. The goal of the evaluation is to contribute to a better understanding of the conditions necessary for achieving best practice, and to draw strategic lessons for the future; the purpose is to assess the performance of UNFPA country offices and FPAs in six selected countries in promoting the reproductive rights and health of adolescents and youth. This analytical summary presents the main conclusions and lessons from the evaluation of the UNFPA Egypt Country Office and EFPA (the Egyptian IPPF affiliate) against the five evaluation themes of: strategic focus, institutional arrangements, policy and advocacy, service strengthening, and information and education. The summary highlights key findings against 10 key questions set out in the original TORs for the evaluation under the following headings: Strategic Focus: The extent to which UNFPA and EFPA: · Recognise and articulate the country-specific socio-cultural factors that impact on the reproductive rights and health of young people; · Recognise and articulate the diversity of needs of young people; · Promote the concept and practice of reproductive rights; and · Are gender-sensitive in addressing RH needs and rights of young people. Institutional Arrangements: The extent to which UNFPA and EFPA: · Contribute to the response of government and civil society to the reproductive rights and health needs of young people; · Provide quality technical support and promote lesson learning and best practice in young people’s reproductive rights and health; · Promote the participation and empowerment of young people; · Demonstrate complementarity, coherence and cooperation with each other; and · Demonstrate relevance, scope and effectiveness in co-ordination arrangements and partnerships with other actors in the field of reproductive rights and health. Policy and Advocacy: The extent to which UNFPA and EFPA are: · Stimulating enabling environments for policy development in relation to young people’s reproductive health and rights. The above issues are explored in detail in the main report, and further elaborated in the discussions on service strengthening and IEC. UNFPA and IPPF Evaluation: Egypt Country Report 2 The Context: Priority Sexual and RH Issues Facing Young People Youth aged 15-24 comprised 20% of Egypt's population in 1996, and in 2001 they constituted over 60% of the unemployed labour force. The priority SRH issues facing young people are early marriage and early initiation of childbearing, continued practice of female genital cutting (FGC), and religious conservatism obstructing the provision of reproductive health information or services to unmarried youth. Consequently, knowledge of STIs, contraceptive methods, or other RH issues is low among adolescents and youth in Egypt, and very limited attention is directed towards male responsibility in reproductive health. Existing reproductive health IEC and services are directed to married women. Strategic Focus of the UNFPA and EFPA Country Programmes UNFPA Prior to ICPD, UNFPA in Egypt supported IEC programmes targeting youth in and out of school with information on population, family planning and the environment. After ICPD, which took place in the middle of the 5CP, there was a stated shift in program focus to youth and NGOs, and a definite broadening of focus from FP to RH issues. UNFPA began to collaborate more closely with youth-focused NGOs, supported the development of an information base on adolescents through funded research, and initiated advocacy efforts against FGC and early marriage. Gender equity had been a focus of the CP for some time. However, there was no significant attention to young people’s sexual and reproductive health services or rights. The 6CP aimed to support implementation of ICPD. Reproductive health services for adolescents were mentioned in the CP document, but did not materialise in practice. Youth were included in the target group for RH service delivery and IEC, but no specific strategies for youth were adopted, and their utilisation of services was not monitored. Information package(s) were expanded to include sexual health or an explicit focus on rights. “Youth” was not defined, little attempt was made to diversify information for sub-populations of youth, and youth were only minimally involved in project design or implementation. Youth were, however, targeted for advocacy and information (including peer education programmes) in several 6CP sub-programmes. Moreover, through advocacy and support for development of the National Adolescent Strategy, UNFPA has slowly but surely influenced the policy environment to accept that young peoples RH is an important issue. The integration of Adolescents and Youth into the National Population and RH Strategy is seen as a major step forward. There is general acceptance that young people require RH information, but not universal acceptance that unmarried young people should be provided with RH services. Activities in the 6CP have therefore paved the way for a more explicit approach to young people’s RH health in the 7CP. Within the 7CP UNFPA has formulated two projects to extend RH services and IEC to young people (e.g. Meeting the RH Needs of Adolescents). EFPA will be an implementing partner in both projects. UNFPA has also sustained advocacy against early marriage and female genital cutting, and is generally regarded as effective in slowly raising acceptance among government partners of the idea that youth have special RH needs. Yet there is still little emphasis on reproductive rights, and discussion of youth needs does not rely on rights- based arguments. UNFPA is well aware of the conservative viewpoints on individual reproductive rights in general, and those related to young unmarried people in particular. Staff pointed to a missing link between the global formulations of the ICPD recommendations and a culturally appropriate translation of the recommendations tailored to the Egyptian UNFPA and IPPF Evaluation: Egypt Country Report 3 socio-cultural and religious context: “Almost all recommendations are applicable but it needs to be presented differently”. UNFPA staff acknowledged these socio-cultural constraints, and rather than create controversy and opposition, have sought to “wrap” young people’s reproductive rights issues in a language that is more culturally appropriate, and therefore acceptable to relevant individuals (religious leaders, politicians, deans, school teachers and other gatekeepers). The term “rights” was specifically avoided. For example, UNFPA agreed to change the title of the controversial “Advocacy on RH and rights” project (see section 4 and 6). Given the complicated and firmly embedded nature of culture, more time and sustained advocacy is needed to build support for young people’s RH and rights. EFPA EFPA has gradually shifted their focus from family planning (FP) to reproductive health (RH). However, until the recent exercise to develop a mission statement and Strategic Plan, the provision of RH information and services to youth was not given priority or explicit focus in programme activities. Several youth-oriented projects have been implemented, but these have been relatively isolated projects, and not implemented within a strategic framework. Funding for youth activities has been a problem, especially since IPPF froze funds for non- service delivery activities from 1999–2002, pending restructuring of the main office and a review of the programme planning and resources allocation process among member FPAs. During this period other donors (e.g. UNFPA and UNICEF) funded EFPA to carry out youth related projects. Young people were involved to some extent in either programme design or design of IEC materials. EFPA also conducted several studies at both national and local levels to identify priority issues, but mainly related to specific projects and local subgroups rather than national advocacy. There have been only minimal attempts by branch FPAs to develop or seek funds for youth projects of their own. EFPA has not addressed the issue of RH services for young people, especially the unmarried. Its services do reach young married women, but with some exceptions these are the educated and well off who can afford to pay. The responsibility of men is almost completely ignored. EFPA has explicitly addressed several rights issues in a series of booklets, in the context of women, religion and reproductive health. EFPA has now put together its new strategic plan covering the period 2003-2007, which provides a framework for focusing on the underserved, in particular young people. This plan intends (among other strategic objectives) to promote youth reproductive rights, and to provide high quality RH information and services to youth. To do so, EFPA will have to introduce new ways to advocate for these rights and provide youth with the services and information they need and deserve. As EFPA was still in the planning phase during the evaluation the plan did not yet specify how they will implement these strategies. Given the need to cover at least a proportion of costs, service provision for youth may be limited to the higher socioeconomic classes, unless they can be cross-subsidised by increasing revenue from other services. The EFPA needs to develop specific strategies and carefully decide its niche in collaboration with other partners. Institutional Arrangements for Implementing Young People’s Programmes UNFPA The capacity and experience of UNFPA and the Ministry of Health and Population (MOHP) to develop youth-directed RH programmes continues to be extremely limited. The Government of Egypt (GOE) has limited absorption capacity (in financial and technical assistance), and attitudes of health staff towards young people’s RH and rights remain traditional. UNFPA has tended to overcome staff inexperience with youth activities by drawing on external UNFPA and IPPF Evaluation: Egypt Country Report 4 expertise, but this runs the risk of undermining the development of technical capacity within the UNFPA CO itself. UNFPA is gradually building up expertise through learning-by-doing, but would benefit from technical expertise in project design and capacity development from the CST. The share of financial resources allocated to young people’s RH activities in past CPs has been limited due to its low position on the CO's agenda. This is redressed in the 7CP, where young people's RH will be the main thrust. UNFPA has had success recently translating formative research from Giza into an effective model for expanded RH services. A parallel process will now be required to develop service strategies for youth. UNFPAs M&E system provides very little information that would allow constructive feedback on project performance during implementation, nor does it provide the information necessary to assess achievement of CP objectives or identify best practices for replication. The design of coherent, manageable M&E mechanisms, with outcome/impact-oriented indicators in the forthcoming pilot youth projects will need special attention. The capacity of the MOHP to design, implement and monitor the projects will also need to be strengthened. UNFPA also needs to rectify its own shortcomings in engaging with, and empowering, youth. Formal mechanisms exist to promote complementarity and co-ordination between the various agencies involved in sexual and reproductive health and rights (SRHR) for young people, and UNFPA plays a leading role in the process. There are some good examples of collaboration and joint funding of initiatives. However, there is room for strengthening the processes to ensure true co-ordination of inputs, synergy and optimal utilisation of resources, rather than mere sharing of information. The United Nations Development Assistance Framework (UNDAF) reinforces the work of UNFPA and other partners in the area of SRHR of young people and reducing gender disparities, although again, the issue of sexual and reproductive rights is not strongly emphasised. UNFPA has played a major role in increasing awareness, but this now needs to be channelled into acceptance of the forthcoming responses to married and unmarried young peoples RH needs, and into the design of services and information that are accessible and acceptable to the diverse needs of young men and women of all socio-economic groups. This will require expertise that does not exist in the UNFPA office and is scarce in Egypt. UNFPA can play a strategic role in accessing expertise and building capacity in-house, and in its partner organisations. Close monitoring of the attitudes of second and tertiary audiences is needed and outcomes should be translated in re-defined messages aimed at these different target groups. The main issue at stake is to move towards an institutionalisation of SRH for young people in the Egyptian culture and development community, and to adapt the RH services according to changing needs. EFPA The EFPA has not had the institutional capacity to design or monitor youth programmes, and staff have not received sufficient training to do so. However, the new organisational structure includes a Youth and Gender Assistant. Some capacity has now been developed within the central office and the partner Institution for Research and Training in Family Planning (ITRFP), in terms of designing manuals for training young people. High turnover of staff at senior levels has compromised both capacity and sustainability, and as mentioned above, lack of financial resources has been a major problem. Output oriented monitoring systems have limited the capacity to assess the effectiveness or impact of IEC programmes for youth. In the context of the new partnership with UNFPA 7CP to implement RH services and IEC for UNFPA and IPPF Evaluation: Egypt Country Report 5 youth, EFPA is charged to develop, pilot and evaluate innovative service delivery models that have potential to offer completely new directions for RH in Egypt. EFPA has integrated gender issues into its organisation to a certain extent, although women are predominantly represented in service delivery jobs. EFPA has not yet institutionalised any mechanism for greater involvement of young people in determining the policies and strategies or programmes of the organisation. Complementarity, coherence and cooperation between UNFPA and EFPA UNFPA and the EFPA have collaborated on youth projects since the mid-1990s, starting with the “Youth Leadership Development Project” funded by UNFPA. The ITRFP developed training curricula, and trained advocates and youth leaders from different EFPA central and local offices. However, co-ordination within the project was not optimal, with training and IEC developments sometimes taking place in parallel, but not shared. And while EFPA was involved in another UNFPA-funded youth project around the same time, there appears to have been little joint working or sharing of best practice between the two projects. Within the 7CP (2002-06), UNFPA and EFPA are working together on the development of protocols and guidelines to support the implementation of a package of youth friendly services; and training of service providers to improve quality of service provision to young people. EFPA will receive funding from UNFPA to implement Meeting the RH Needs of Adolescents in four governorates (Dakahleya, Alexandria, Qualiubya, Menufeya), and will also be an implementing partner for Support to the RH Services at MOHP (with focus on adolescents and youth). These plans will challenge EFPA to explore the possibility of serving as a formative and instrumental partner of UNFPA in youth-oriented service provision, advocacy and IEC, while sustaining implementation within government services. If youth innovations are successful, all three partners would be well-positioned to co-ordinate a scaling up of best practice. As noted above, both UNFPA and EFPA suffer from lack of significant staff expertise in youth programme development or implementation. These common needs for staff development in youth programmes (likewise in M&E), suggest an opportunity for shared capacity building. Policy development and reform UNFPA UNFPA’s advocacy and support for IEC has slowly but steadily been contributing to the development of a body of informed people who can lobby for and influence policy change, and create a positive policy environment for engaging with youth SRHR and rights issues. The acceptance of the National Population and Reproductive Health Strategy (NPRHS), which is regarded as a landmark. UNFPA has also, to some extent, been attempting to lay a foundation for attitudinal change at community and family level though mass media campaigns and localised IEC programmes. However, to date there has been insufficient attention to influencing the attitudes of critical gatekeepers, such as parents, religious leaders and service providers. The need for this is well articulated in the National Adolescent Strategy (see section 1.2), but not yet operationalised by UNFPA or its partners. The limited progress in the area of access to RH services and the promotion of rights needs to be assessed not only in the general socio-cultural context, but also in the context of the working environment. Although UNFPA has promoted attention to youths’ specific RH needs since 1997, no operational guidelines for implementation have been developed. RH and rights in general, and for adolescents and youth in particular, is not an accepted concept UNFPA and IPPF Evaluation: Egypt Country Report 6 amongst medical staff, and has had a restricted (albeit growing) acceptance within the MOHP. The environment is slowly changing, and it is expected that more progress can be made in the 7CP. The National Population Policy has partially integrated some crucial adolescent- and youth- related strategies, and the new MOHP minister has publicly expressed an intention to devote more attention to young people. A population information system model (an outcome of 6CP) can be used to facilitate policy dialogue, to measure Egypt's progress in achieving national and international goals, and to determine whether and to what extent the MOHP applies the ICPD recommendations and other commitments to international agreements. At the same time, UNDAF (and UNFPA) have assumed a stronger role in supporting policy dialogue and reform, consistent with national priorities. However, given the limited capacity of the key stakeholders, including UNFPA, much will depend on the ability to mobilise expertise in SRH of young people to guide the operational planning of the 7CP. The thematic evaluation highlighted that efficiency could be enhanced by using qualified resources such as a Cairo-based national advisory group that has expertise in the institutional and policy environment. EFPA EFPA has not played a significant strategic role in influencing policy or legislative reform, but has contributed to the debate by raising awareness of relevant issues such as FGC, early marriage, and women’s rights. In recent years, the EFPA has initiated national action in the areas of women’s empowerment and youth. EFPA advocacy on the expansion of women’s clubs, the role of women in policy, and RH awareness-raising among girls before marriage (e.g. on premarital examination, or delaying age of marriage) have been recognised by government, and considered appropriate by the Egyptian Parliament. EFPA has a good level of understanding of the policy environment in Egypt. Over time, they have created close links with many national and international institutions/organisations working in reproductive health and rights. They have the potential to be more fully engaged in, and influence, the policy debate, particularly given their experience of implementing policy in the field. However, this would require a more pro-active and objective role, and perhaps compromise their impact as a major service provider. Strengthening RH Services Young people's RH services in Egypt remain a major gap to be filled by programme interventions. Despite high fertility and some limited evidence of youth abortions, young people’s service needs are poorly understood, and therefore largely neglected. UNFPA UNFPA support for RH service provision for young people so far has been limited to support for the integration of FH and RH into PHC services of the Ministry of Health and Population (MOHP). In practice, however, service delivery has largely addressed married female clients, an unknown percentage of whom fall within the 10-24 age group. Although this was a best practice project in terms of integration, institutionalisation and sustainability, it missed the opportunity to collect data disaggregated by age and marital status of clients. It also did not address the issue of RH services for unmarried young people. However, there are some elements of this best practice approach that can be adapted to the needs of young people in the next CO, which focuses specifically on improving access to RH services and information for young people, married and unmarried. The CO is currently drafting plans to embark on a project entitled Meeting the RH Needs of Adolescents, with EFPA, which will include UNFPA and IPPF Evaluation: Egypt Country Report 7 service provision for youth in a variety of conventional and unconventional settings that are yet to be elaborated. While this project can draw on the successful experience of the RH Framework programme, Meeting the RH Needs of Adolescents will require a solid knowledge base before it can proceed. An external consultant is currently investigating young people's perceptions of youth-friendliness. Given the importance of gatekeepers to the lives of younger cohorts, research is also needed to better understand the attitudes of parents and community members to young people's utilisation of services. Distinguishing between the needs of sub-groups within the population of young people based on their circumstances, or access to facilities will be critical to the provision of relevant and effective RH services to each group of potential clients under this project. A deeper understanding of provider attitudes towards youth would also be useful. EFPA Services provided by the EFPAs are generally perceived as high quality, and client rights such as privacy, confidentiality and choice are respected in most cases. There is definitely room for improvement in service quality and standardisation of such services for all EFPA FP/RH affiliated clinics. Some FPA clinics have responded to the diversity of local needs of women with innovative approaches. However, most are dictated by the need to recover costs, and thus there is limited possibility to serve less advantaged groups. Young married women are only reached by default. Premarital examinations are provided for young unmarried men and women, but these are focused on exclusion of medical problems. They do, however, have the potential to provide an opportunity for a broader range of RH counselling services. There is a strong intention and commitment to serve young people, and the new UNFPA partnerships will provide a crucial opportunity to test options for doing so. Staff expects that a high quality of services will attract youth, but that remains to be seen. Given concerns about communication and confidentiality, private facilities may be preferred. Reproductive Health Information and Education UNFPA UNFPA has been very active in its promotion of RH IEC in all CPs. Several projects generated materials and knowledge related to RH of youth, both in and out of school. Some were based on the principle of peer education, others were more formal and top down (e.g. the school education programme). The content of the formal IEC programmes has remained conservative and limited, especially for in-school youth. However, other advocacy materials have shifted perceptibly away from FP to RH, and have been progressive, addressing culturally sensitive issues such as FGC and early marriage, and to a lesser extent gender- related violence. Though significant ground has been broken by some of these topics, other culturally sensitive topics such as forced marriage, Urfi1 marriage, delaying first birth, cousin marriage, and HIV/AIDS have received less attention. Furthermore, many of the written materials are not at all user-friendly, being theoretical and rather dry and unappealing to young people. Not all have been appropriate in terms of images and language. Some good attempts have been made to reach less educated audiences through TV and drama, but these materials need to be developed more systematically. Indeed, many of the materials have been intended for a wide audience, from 1 The Urfi marriage is a marriage without an official contract. Usually a paper, stating that a couple are married, is written and two witnesses sign it. Undocumented Urfi marriages are increasingly popular among Egyptian youth. The high cost of marriage forces many young couples to wait several years before they marry. UNFPA and IPPF Evaluation: Egypt Country Report 8 MOE officials to young farmers, and there has been little attempt to segment the audience. IEC approaches adopted so far have either subsumed young people into larger population categories (e.g. rural dramatic play audiences or women PHC unit clients), or have assumed a homogenous cohort of young people (e.g. secondary school students or youth trainees). Although some projects carefully assessed the needs of the audiences targeted, UNFPA was inconsistent in its use of evidence-based planning for its IEC approaches, and did not rigorously pre-test materials. UNFPA should be commended, however, for its achievements in reaching out to marginalised groups who would otherwise not have access to RH IEC, such as young farmers and poor out-of-school adolescents, through deliberate outreach and TV. RH rights, especially those of the individual as opposed to the couple, have not been directly addressed by UNFPA in its IEC efforts, but attempts have been made to address them implicitly. When IEC approaches promoted FP and criticised traditional practices related to RH (such as FGC), they tended to do so by arguing that this enhances positive health outcomes or serves national interests. Though this may be perceived by some to dilute the rights message, this can be considered an adaptation of RH concepts in response to socio- cultural realities. Although IEC outputs have been carefully documented, it is not possible to assess the outcomes of these interventions in terms of attitudes and behaviours changed among youth as a result of exposure. Given the sensitive nature of RH topics in the Egyptian context, and the danger of conservative backlash to interventions that challenge traditional norms, audience reactions should be monitored more closely. UNFPA staff has succeeded in a number of these projects in identifying and building on competent IEC expertise elsewhere. Partnerships have also been forged to share costs and human resources. Such partnerships also facilitate the mainstreaming of these projects into partners' continuing activities and heighten sustainability. There are preliminary indications that the latter two activities are highly sustainable. UNFPA's role consisted of providing technical assistance and scientific evidence to playwrights and broadcast media professionals, for example, who were called upon to carry out project activities. However, with some exceptions, young people and other target groups were minimally involved in the conceptualisation, design, review, pre-testing, and monitoring of IEC strategies and materials. EFPA Review of IEC materials produced by EFPA revealed that most of the materials were produced for educated target groups. These materials focused on family planning with the exception of materials produced on FGC. Also, most of these materials were directed to advocates and trainers rather than to young people themselves. Most of the materials were in print formats. Other forms of IEC materials, especially audiovisual, did not get enough attention. Moreover, individual FPA local offices produced their own IEC materials sometimes with no co-ordination with the central office. Local offices and clinics usually use MOHP brochures and general posters rather than producing their own. However, youth volunteers developed IEC materials in the context of the “Youth to Youth” project for their local youth audiences, but these materials have not been evaluated. Young people interviewed during the evaluation (during the in-country opinion study, in the youth workshop and well as field interviews), seemed to have some knowledge in relation to SRH issues, but requested much more information than already offered to them by media and surrounding health personnel. UNFPA and IPPF Evaluation: Egypt Country Report 9 KEY FINDINGS AND RECOMMENDATIONS Both Organisations · Although the foci of UNFPA and EFPA Programmes have shifted from family planning to a broader concept of RH that includes RH needs and rights of youth, most field programmes in Egypt continue to focus their efforts on family planning (FP) for married women. Efforts to address youth SRH to date have featured advocacy and education, and UNFPA has been effective in raising awareness and policy dialogue over youth SRH needs. · RH services in Egypt feature pregnancy-related care and FP targeted to married women. Most service settings cannot provide confidentiality or privacy, nor have staff capacity to counsel youth, and therefore the existing clinic models are not an appropriate environment for a serious mobilisation of SRH care for unmarried female or male adolescents. · Nonetheless, the UNFPA 7CP has made an explicit commitment to expand SRH services to youth, and EFPA will be an implementing partner in this initiative. To accomplish this goal, innovative models will be required for piloting and testing, and both organisations will need to upgrade staff capacity. Expertise in youth-directed programming is severely limited in Egypt at present, and a majority of those involved in the RH field who were consulted during the Evaluation did not clearly recognise youth as a social group with distinct SRH needs. · Monitoring and evaluation systems within UNFPA and EFPA projects in general, including those directed to youth, are almost exclusively process-oriented and do not monitor progress towards achievement of outcomes and objectives, or collect and analyse information on the needs or response of different sub-groups of youth. Hence, progress on youth initiatives will be difficult to document. · With the exception of the “Youth Leadership Project” of UNFPA, there has been limited youth involvement in needs assessment, programme design or evaluation within either organisation. Many staff members at EFPA and UNFPA are still not convinced that youth can make fruitful contributions. Focus group discussions (FGDs) with youth are being implemented to collect ideas for the 7CP, but there are no plans to include youth in formal decision-making. · New concepts such as gender sensitivity and rights-based programming have not been translated into practical policies relevant to the Egyptian context, leaving staff unclear of how to integrate such concepts into their work. Where addressed, gender sensitivity is restricted to a heightened focus on women. · Arrangements for financial and technical sustainability are poorly addressed by the implementing agencies, in part due to ambiguities over prospects for continued funding, and limited experience with fund-raising and planning. UNFPA and IPPF Evaluation: Egypt Country Report 10 UNFPA · The understanding and operationalisation of new (global) concepts such as those of gender, RH, and rights will require time, sustained outreach, and reinforcement of efforts. Most projects, in particular those directed to short-term RH and rights interventions, express high and unrealistic objectives and expectations. · To date, UNFPA has taken a “softly-softly” approach to the promotion of rights-based objectives, and avoided explicit references to individual reproductive rights. Nonetheless, their projects implicitly support the right to SRH information and self-determination, and they have challenged practices such as FGC and early or forced marriage. While more explicit interventions with young people on such issues may admittedly be ineffective, or even harmful, the agency has undertaken little outreach to male religious and community leaders, parents, or other “gate-keepers” of tradition. · UNFPA has given little attention to the issue of gender violence, yet many of those interviewed claim this is an issue of urgent importance for youth. · UNFPA has limited capacity within the country office to implement youth-friendly projects, including those planned for 7CP, as prior projects have depended heavily on external expertise. Increased staff capacity in youth SRHR is urgently needed both in-house and among partner organisations (including EFPA and government), in order to implement “Meeting the RH Needs of Adolescents”, and related projects. EFPA · EFPA has undergone a difficult phase with rapid turnovers among senior staff, reductions in funding, and difficulty retaining volunteers. While CSI clinics are generally regarded as offering higher quality services than other providers, they face increasing competition from MOHP for paying customers. Sustainability remains a key challenge. · Standards of service in EFPA clinics are not yet developed to address young people as a special target group, with special access, privacy and information needs. The EFPA (e.g. Clinical Services Improvement (CSI)) market niche has mainly been higher quality, and higher cost, services for middle class women. Current services provide access to young people (mostly young married women), only by default. How EFPA plans to modify their approach, upgrade staff capacity, and create innovative points of access for unmarried female and male youth is unclear. · Branch FPAs are unaware of the existence of youth-oriented IEC and training materials that could inform or aid their ongoing and planned activities. Existing manuals such as the ITRFP/ CEDPA Youth Leadership manual, New Horizons, and New Visions are not well disseminated or promoted. UNFPA and IPPF Evaluation: Egypt Country Report 11 Complementarity of UNFPA and EFPA · The two organisations have worked effectively together on SRH projects, including youth- related projects for many years, and UNFPA continues to fund EFPA as an implementing partner. Plans for the UNFPA 7CP include EFPA as an implementing partner for two challenging youth-directed projects. · Both agencies require more in-house expertise in youth-related SRH to implement their joint plans for 7CP, and this poses an opportunity for potential cooperation in staff development. · Inefficiencies from duplication of effort have been noted in past projects on training peer educators and developing IEC materials. Recommendations: Common recommendations to both organisations for staff development, strengthening monitoring and evaluation, and greater outreach to “gatekeepers of tradition” suggest opportunities for cooperation. For both organisations · Staff at implementation level should be trained on how to operationalise the new directions proposed by the Country Programmes. The “Human Resource Development Strategy” needs to be strongly linked with the “Adolescent and Youth Strategy” and “FP and RH Strategy” recently adopted by the MOHP. · Assessment of the SRH needs of different groups of young people should be conducted to inform the planned new initiatives in service outreach and IEC. Efforts should be made to pilot a range of “access strategies” to accommodate disparities in access and acceptability across different social groups. · Mechanisms and operational guidelines should be devised to involve and empower youth. The inputs of young people, both male and female, should be incorporated into the needs assessment, service delivery plans, and M&E, and their perspectives on ‘quality’ and ‘appropriateness’ should be used to inform future activities. · Monitoring & evaluation should be strengthened by adding baseline and follow-up measures to interventions to better assess achievements. · More focused activities are needed to promote the health interests and information needs and rights of youth among parents, men, religious leaders and other gate-keepers of tradition. · Concepts of rights and gender should be translated into practical, locally-relevant examples that are easily conveyed to UNFPA and EFPA staff (and their collaborators), adult decision-makers, and young people themselves. Shared responsibilities of both boys and girls in SRH needs focused attention. Collaboration should be considered with sectors that have the potential to promote gender, right and RH responsibilities among males (professional syndicates, sports groups, etc.) UNFPA and IPPF Evaluation: Egypt Country Report 12 · Co-ordination of IEC materials between the two organisations (and with other agencies) is required to reduce duplication, and ensure that technically sound materials are distributed to the appropriate audiences. The validity and relevance of messages and media should be routinely assessed through field tests. Local initiatives, such as materials developed by youth in the EFPA covered governorates should be tried. · Prospects for future funding need to be made explicit to implementing agencies / branch offices at the outset of projects. Gradual withdrawal of funds and technical assistance on fundraising should be built into programmes to enhance sustainability. UNFPA · The immediate objectives of projects within the 7CP should be realistic in terms of what can actually be achieved given the historical, socio-cultural, religious and local context, and the time frame in which the activities are going to be implemented. An approach that explicitly combines short-term practical projects with long-term strategic social outreach is recommended. Defining such objectives in a participatory manner with implementing partners, and with youth input, may be especially fruitful. · UNFPA is encouraged to promote the establishment of national mechanisms to better assess and understand gender violence at all ages, including among youth, and to provide leadership in developing strategies for reducing gender violence. · Staff from previous youth oriented activities should be mobilised to mentor staff within UNFPA and partner organisations, in an urgent effort to increase capacity for carrying out the youth-related initiatives planned for the 7CP. EFPA · Innovative models for service venues and approach should be piloted and evaluated to create youth friendly clinics (or centres), and to allow a mode of access that maintains privacy. · Service providers should be encouraged to collect data on clients, including data on age, sex and (where possible) marital status, in order to assess utilisation patterns among young people, and allow tailoring of services to young women and men. · Standards of service, and staff capacity should be adapted to tailor quality services and IEC to youth SRH. Training of service providers should address the diversity of needs of subgroups, and providers’ experiences in this context should be well documented and used to improve training programmes (bottom-up approach). · Proper counselling for young people should be emphasised in all venues of pre-service and in-service training courses. Staff attitudes towards young women’s and men’s reproductive health and rights should receive greater emphasis. All direct service workers need training in the ethical responsibility of keeping sensitive information confidential. · Existing youth-oriented curricula and other materials should be utilised more fully and integrated into the activities of youth cadres who are still active, in order to provide a non-traditional mode of reaching other young people. UNFPA and IPPF Evaluation: Egypt Country Report 13 INTRODUCTION The Ministry for Economic Cooperation and Development (BMZ) of Germany, the Danish Ministry of Foreign Affairs, the UK Department for International Development (DFID), the Netherlands Ministry of Foreign Affairs, and the Norwegian Ministry of Foreign Affairs are jointly sponsoring an evaluation of the contribution of the United Nations Population Fund (UNFPA) and the International Planned Parenthood Federation (IPPF) to addressing the reproductive rights and health needs of young people2 - and especially adolescents - in the period since the finalisation of the Programme of Action (POA) developed at the International Conference on Population and Development (ICPD) in 1994. The evaluation focuses on six country case studies: Tanzania, Burkina Faso, Bangladesh, Egypt, Nicaragua and Vietnam undertaken between March and May 2003. The findings from these six country studies will be synthesised into a final report to be presented at an international workshop in December 2003. Objectives of the Evaluation The overall aim of the evaluation is to clarify how UNFPA and IPPF contribute to the implementation of key aspects of the ICPD Programme of Action, relating to the reproductive rights and health of young people. UNFPA and IPPF have affirmed their commitment to the ICPD framework; central to which are the notions of gender empowerment, equity, and a rights based approach. IPPFs commitment to a rights based approach is outlined in the IPPF Charter on Sexual and Reproductive Rights (1995), and in the objectives and strategies of Vision 2000. The goal of the evaluation is to contribute to a better understanding of the conditions necessary for achieving best practice, and to draw strategic lessons for the future. The purpose is to assess the performance of UNFPA country offices and FPAs in selected countries (see below) in promoting reproductive rights and health (with the aim of achieving behavioural change), with a particular emphasis on adolescents and youth. Composition, Timing and Schedule of the Country Evaluation The local partner for the country evaluation was Health Care International and the Population Council. The international team for the country evaluation was Dr. Tawhida Khalil (team leader), Ms. Juliette Boog (international team member) and Ms. Rania Salem (national team member). The evaluation team worked on this evaluation assignment in the field from 3rd May to 23rd May 2003. A variety of activities were conducted during the time of this evaluation. These include: 1. Stakeholder workshop to provide proper conceptualisation among UNFPA, EFPA and other major stakeholders in country about the evaluation’s scope, objectives, and mandate. The workshop also provided a good opportunity for participants to share experiences and express challenges in working with young people at present and in the future. 2. Youth workshop to give insights about differences in perceptions between stakeholders and youth in sexual reproductive health and rights. 3. Interviews with key informants (including central and implementation level staff, as well as beneficiaries) 2 The evaluation adopts UN definitions: adolescents are aged 10-19 years, youths are aged 15-24 years; young people include both categories (10-24 years). UNFPA and IPPF Evaluation: Egypt Country Report 14 4. Review of projects’ documents including implementation plans, reports and policy related documents 5. Interviews with other donors and stakeholders with young people's SRHR projects in Egypt, e.g. UNICEF, USAID and the European Commission. A detailed itinerary of the field work undertaken by the evaluation team is attached as part of Annex 1. Report Format This report is designed to document the process, activities and results of this evaluation exercise. It is divided into six sections; these are: 1. The Country-specific context. 2. The Strategic Priorities of the Country Programmes. 3. Institutional Arrangements. 4. Enabling Policy Development and Reform. 5. Strengthening RH Services. 6. Promoting RH Information and Education. Each of these sections is then subdivided to present each organisation separately; UNFPA & EFPA each have one separate sub-section. The major criteria used for assessment of organisations performance were: relevance, capacity, integration of rights, efficiency, effectiveness and sustainability. UNFPA and IPPF Evaluation: Egypt Country Report 15 SECTION 1: THE COUNTRY-SPECIFIC CONTEXT 1.1 Demographic & Socio-Economic Context Demographic and health indicators The population of Egypt in 2001 was estimated at 69.5 million, making it the largest, most densely settled population among the Arab countries. 57.5% of the population live in rural areas. 94% of the population are sunni muslim and 6% are Coptic Christians and other religions. A significant proportion of the population is aged 15-24 year olds. This group increased from 15% of the total population in 1986 to 20% in 1996 (Census 1996). The dependency ratio has decreased from 87 in 1986 to 70 in 1996, reflecting recent fertility decline (UN 2001), and is higher in rural than urban areas (EDHS 2000). Annual population growth rate is now 2.2%. During the past 20 years, the Total Fertility Rate (TFR) has decreased from 5.3 to 3.5 births per woman in 2000, although recent projections indicate a plateauing. The TFR in urban and rural areas was 3.1 and 3.9, respectively. Factors contributing to fertility decline include the availability and use of effective contraceptive methods (51.5% of married women), a steady increase in the age at which women marry, and nearly universal approval of family planning for married couples. The median age of women at first marriage in Egypt has increased to 19.5 years, 21.2 in urban areas and 18.1 in rural areas. Although fertility has declined, with nearly 37 per cent of the population below the age of 15, the population is expected to grow at least until 2025, reaching an estimated 120 million by 2030. Life expectancy at birth is 67 years (68 for women). Infant mortality has decreased from 73 per 1,000 in 1995 to 55 per 1,000 in 2000 (UNFPA 2001). The maternal mortality ratio has dropped considerably in recent years, and now stands at 84 per 100,000 live births (NMMS, 2000). Delays in seeking medical care were a factor in 30 percent of maternal deaths. Almost half of all mothers and 58% of rural mothers do not access antenatal care. Iron deficiency anaemia is common amongst women - 45% among pregnant women and 32% among lactating women. HIV prevalence in Egypt is low (less than 0.1% in adults). 314 AIDS cases had been notified by October 2001, mostly in men age 30-44 years. Poverty The Economic Reform and Structural Adjustment Programme of 1990/91 have been widely credited with restoring the macroeconomic structural soundness of the Egyptian economy. GDP growth rose continuously from 5.0% in 1996 to 6.4% in 2000 and GNP per capita in 2000 was estimated to be US $1,500. However, liberalisation policies also appear to have resulted in higher unemployment and increased levels of poverty in some geographic areas. According to the living conditions survey in 1995/96, 23 percent of the population lived below the minimum basic needs poverty line3. 64 % of the poor and 74 % of the critically poor live in rural areas. Youth in Egypt carry the largest burden of unemployment, constituting over 60 percent of the unemployed labour force. Only one third of 15-24 year olds is working, and 50% of women aged 15 to 24 are neither attending school nor working. More than half of the young women in the labour force have intermediate and above education, but are unemployed (The Population Council, 2001). The inability to secure gainful employment impedes the process 3 i.e. had insufficient means to meet the locally-defined cost of food and other minimum basic needs UNFPA and IPPF Evaluation: Egypt Country Report 16 of setting up a household, leading to feelings of inadequacy among males, on whom the material responsibilities associated with marriage and family formation fall. Egypt’s labour force is increasing by 500,000 new entrants per year, demanding vigorous employment creation if youth unemployment is to be reduced (WB 2000). Access to education Access to education has greatly improved, and school enrolment has been steadily increasing. The overall gross enrolment ratio for basic education (8 years) is now 99% for boys and 93% for girls, although regional variations are significant. Combined basic and secondary education enrolment is 81%. 29% of the population (23.5% of women) have secondary or higher education, but this falls to 14% of women in rural areas (EDHS, 2000/01). Recent government interventions have significantly improved enrolment ratios for girls in rural disadvantaged areas, resulting in a 31% increase in girls’ enrolment between 1991 and 1998, double the rate of increase for boys. However, the gender gap remains large in some areas such as rural Upper Egypt. Once girls enter school they are nearly as likely to continue as boys, and educational attainment is virtually the same. However, according to the Egypt Demographic and Health Survey (EDHS 2000), 16% of 6- 15 years had either never attended or had dropped out at some point. The proportions never having attended school are nearly identical for boys and girls living in urban areas (6.4% and 6.9%), but there are marked differences between the level among boys (9%) and girls (19%) in rural areas, and significant regional differences (26% of girls in rural Upper Egypt). The reasons for dropping out of school are varied and are not consistent between documents reviewed. Some claim that the predominant reason for dropping out of school is for marriage or because educating a girl is not important4. However, in the EDHS 2000, eight in ten mothers cited child-related factors as the reasons for dropping out of school, particularly the child’s lack of interest in school (54%) or the childs failing or repeating a grade (38%). Mothers, especially in rural areas, were somewhat more likely to cite costs as a reason that a child dropped out of school for girls (24%) than for boys (18%), as well as custom or tradition (16% and 1% respectively). Current socio-economic circumstances, in addition to the adoption of economic adjustment policies, have contributed to pressures on vulnerable families, often leading to school dropout and early entrance of children into the labour market5. Female-headed households, which are most common in urban areas, are often uneducated, earn less than comparable male-headed households, and are twice as likely to have children aged 6-15 working to support the family. The overall adult literacy rate (15+ years) is 62%, but only 49.6% of adult women are literate. In seven governorates, less than 40% of women are literate. In 1997, 59% of girls and 75% of boys aged 15-24 were literate. Illiteracy is more prevalent in rural areas and amongst the poor (EHDR 2000/01). Access to information Young participants (aged 14 - 23) in the focus group discussions cited television as their most important source of information by far (89% of all homes and 84% of rural homes possess a TV). TV is watched by the whole family, “even those who stay at home like housewives”. TV spots often initiate family dialogue and can even “break sensitivity about 4 The National Adolescent Strategy (NAS) uses data collected in the 1997 Adolescence and Social Change in Egypt (ASCE) survey 5 The Situation of Egyptian Children and Women. 2003 UNFPA and IPPF Evaluation: Egypt Country Report 17 some embarrassing issues”. However, they were not always as informative as they might be. “Media Programmes (on reproductive health) are (too much) talking without effect, guest speakers are not professional, answering all questions in the same (monotonous) way and commercial ads frequently interrupt the programme” Female FGD participant In contrast the role of the radio has become much less important. Magazine and newspapers, including the comics of Al-Ahram daily, were also cited as useful sources of reproductive health information. The school curriculum was a useful source of information on human reproduction and some reproductive health issues, such as family planning, and felt to be delivered in a safe and reliable context, allowing for discussion. However some teachers were perceived to be too shy and embarrassed to discuss “really important issues”. Parents are considered a trustworthy and experienced source of information, but are frequently either unavailable (especially fathers), not educated enough, or not able to convey information. In urban areas, some young people felt the relationship with parents was too tense. Trustworthy teachers and social workers at school were useful sources, but students were fearful of being labelled as “students with problems”. Religious leaders were another useful source, giving information that was highly significant for most participants. Experience with seminars and group discussions were mixed. Books were seen as a potentially useful source of information, but are expensive or unavailable. Most would prefer to consult them in the privacy of a public (not school) library. None of the participants had seen any of 10 publications of the Egyptian Society for Family Planning. School doctors were perceived as too busy, though private practice doctors as more helpful. Friends and colleagues were an important source, though most felt that they would be no better informed. Telephone and internet consultation were thought to have potential because of anonymity. Posters were not perceived to have any value. Gender relations and status of young women “The one piece of information that frightened me the most was that roughly 60% of women admit to the fact that they "deserve" to be beaten when they commit, what to me are such, trivial errors. It seems that the self-esteem of women has been trampled on for so many generations and it has sunk low enough to reach this abyss of emotional numbness”. Extract from the Summary of the National Adolescent Strategy Egypt is a signatory to the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) in 1981 - with a number of reservations - Egypt also participated actively in both the 1995 Beijing Fourth World Conference on Women and Beijing +5, and committed itself to the Beijing Platform of Action. However, gender disparities in Egypt remain significant. Women have little control over assets, and limited decision-making authority in relation to marriage, accessing health care and childbearing. According to the EDHS 2000, 28% of women reported that getting permission to go to a health facility posed a big problem in accessing health care. This rose to 39% for 15-19 year olds. Girls are much less likely to participate in paid work, and have heavier domestic responsibilities. Girls and women do not enjoy the same recreational benefits as men, particularly in rural areas and crowded urban settings. Both women and adolescent girls suffer harassment in public places. Although the rights of women to serve in the judiciary or in the legislative powers is UNFPA and IPPF Evaluation: Egypt Country Report 18 conferred by law, very few women stand for election or are nominated by their parties because of perceptions that their candidatures will not be successful: there are only two women judges in Egypt and few in Parliament or local authorities. Many women lack awareness of their rights, and a large proportion of women are not registered at birth: 42% have no identity cards. As in other settings, poverty intensifies gender-based inequities. Egyptian society still holds traditional attitudes: children come first, men are the breadwinners, and women who work must combine domestic responsibilities with paid employment. Perceptions of gender identity in Egypt are strong and patriarchal. Males are presumed to be authoritarian in their relations with women, to uphold the segregation of gender roles, and to take control of fertility decisions. Women are expected to be generally submissive to men and confined by social norms to roles within the family. Men are still not fully involved in bringing up children. This is seen mostly as the domain of the mother, a view that is reinforced by popular culture and the media. Recent data suggests that, while many aspects of Egyptian life are changing rapidly, young people do not appear to be challenging gender roles6. A survey of adolescents found that the vast majority of both males and females agreed that the wife “needs her husband’s permission for everything”. Preferences for segregated gender may come into conflict with changing economic and social realities for families. Discussion of gender roles is therefore an important topic for debate in youth clubs and NGO programmes that are preparing young people for adult responsibilities. Analysing the same data, Mensch et al found strong gender differentiation in socialisation. Egyptian girls in adolescence traditionally experience an abrupt end to the relative freedom and mobility outside the home, to ensure chastity and preserve family honour. Boys on the other hand are permitted greater autonomy and mobility, and are expected to increase the amount of time devoted to work outside the home and community involvement. Schooling has had a major impact on those patterns, extending the ages when girls are able to be out in public, increasing contact between boys and girls, and delaying the onset of work. However, girls, throughout adolescence, spend much of their non-school time within the home, whilst boys are much more apt to engage in activities outside the home. Although 50% of schools are mixed before age 14, only 15% of schools for ages 15 -19 are mixed. The greater physical mobility of boys suggests that communication of reproductive health messages could be effectively mobilised for young males through neighbourhood centres, sports facilities, work sites, and other gathering places. On the other hand, girls’ greater times spent in the home will require creative programmes to carve out “safe spaces” where they can gather and learn. As in most Arab societies, family members play a central role in shaping the values and self- conceptions of young people, who typically live at home until marriage and remain dependent on elder family members for financial and emotional support as young adults. 1.2 The Policy and Legal Context National Policies and Strategies relating to young peoples’ health and rights Children, adolescents and young people stand very high on the government’s priority list in recognition that this age group - up to 18 years old – represents 30 million individuals, nearly 50 % of the Egyptian population, and holds the key to the country’s development. Young people over 18 years old are regarded as adults. Despite the recognition of their importance to development, there is no general National Youth Policy. 6 Adolescence and Social Change in Egypt (ASCE), El-Tawila et al, 1998 UNFPA and IPPF Evaluation: Egypt Country Report 19 National Health Policy Until the last few years, Egyptian adolescents have received limited attention and only as part of more general demographic studies. Youth has been considered as part of the general community as far as health is concerned, with no special emphasis on specific services or activities directed to youth. They have not been isolated as a special segment of society and have not been the subject of special demographic surveys that have focused on their unique characteristics and needs. Following the ICPD, the Ministry of Health and Population (MOHP) drafted a Population Policy in 1996 that specifically addresses the group termed fatayat (girls). It pledges to provide health care to adolescent girls prior to reaching marriage age, and committed itself to conducting premarital examinations and counselling sessions for young people. The same policy states that every citizen has the right of access to quality services. Although this is a universal right, particular attention is paid to women, as they bear the risks associated with pregnancy and delivery, and are typically responsible for family health care. The MOHP also developed several initiatives addressing youth in collaboration with other ministries like Ministry of Information and Ministry of Youth. The MOHP developed a “National Adolescents Strategy” in 2001, supported by UNFPA. The Strategy covers general areas of adolescent health (including access to services, nutrition and development), as well as reproductive health, family relationships and violence, the media, adolescent empowerment, gender equity, male involvement in reproductive health, and Female Genital Cutting (FGC). It clearly distinguishes between never-married adolescents, who “need to be educated on all RH matters”, and the married adolescents “who in addition to being instructed on matters of RH, need guidance and provision of services for FP, maternity, breast feeding, care of their infants, contraception”. The document proposes to approach adolescents indirectly, because they lead sheltered lives, and because “many of the problems of adolescents are not of their own doing but are brought about by the restraints that society imposes upon them”. It stresses the need to change the behaviour of others towards adolescents: parents, teachers, social workers, the media, health service providers, religious orders. “The capricious and irrational control over the lives of adolescents is a violation of their indefatigable right to fair treatment, dignity and freedom of choice. The prejudice and gender bias that parades as family values, must be uprooted from our society before adolescents have a glimmer of a chance to survive their transition into adulthood, and before these so- called values percolate into the next generations. The focus of attention of this strategy is therefore the Egyptian family and not just the adolescents”. Extract from the National Adolescents Strategy Strategies suggested for increasing access to health services include encouraging private practitioners to set up practice near schools. It is also stated that putting RH in the curriculum “in a palatable way for adolescents may be a difficult, fraught with many cultural obstacles”. Therefore various other strategies for information dissemination are suggested - posters, pamphlets, TV spots, internet. Parent counselling to enable them to communicate better with their children is also suggested. The strategy itself was not followed up by any operational plans, but the document has contributed to the development of the Adolescents and Youth Strategy, which is one of 11 strategies in the new National Population and RH Strategy (NPRHS), 2003. UNFPA and IPPF Evaluation: Egypt Country Report 20 The Adolescents and Youth Strategy aims to improve and upgrade adolescents and youth in physical, social, cultural, health, religious and economic aspects. The Ministry of Youth (MOY), Ministry of Education (MOE) and Ministry of Social Affairs (MOSA) will be the key players. Although health is mentioned in this strategy, there is no explicit attention to the SRH of these age groups and no cross-references to other strategies. The role of the MOHP in implementation of this strategy is not explicitly stated, as RH service delivery is included under another strategy, the Family Planning and Reproductive Health (FP/RH) Strategy (see below). Other strategies also include, or have the potential to include youth. The FP/RH Strategy supports the development of accessible and comprehensive FP/RH services in locations “preferred by women and youth”. It states that RH clinics will be established in schools, which are covered by health insurance, to provide reproductive health education and counselling services for school pupils, especially teenagers. These clinics will be linked with social services such as Women Clubs and Youth Centres. However, no explicit reference is made to provision of RH services for unmarried youth, nor to the capacity development of staff and institutions to respond to the specific needs of youth. Although many service providers in different sectors have been trained to provide FP/RH services, the emphasis on youth specific RH topics has been limited. More donor agencies are now putting this issue into their action plans and priority agendas. The Family Support and Protection Strategy aims to raise awareness against wrong concepts and the disadvantages of gender discrimination (early marriage, early and repeated pregnancy, female circumcision and preference for male children). The Information, Education, and Communication (IEC) Strategy will, inter alia, integrate FP/RH concepts in school curricula and diversify the IEC programmes about FP to attract the different segments of the population. The Improvement of Women’s Status Strategy will increase the focus on women’s development/empowerment related issues including education, income generation, legal rights and violence against women. However, no explicit reference to youth is made and young people are included as part of the overall population to be served. Other state policies and programmes, such as the National Adult Education literacy programme, have also sought to enhance young people's reproductive health knowledge, with content on population issues, family planning and reproductive physiology. Education concerning sexual health and rights is not included. The National Education Act and Policy Within the framework of an educational reform programme that began in 1991 with the declaration of education as a matter of national security, a huge investment has been made in expanding access to and improving the quality of schooling. The topic of sex education in schools was discussed by various interest groups. The conclusion of the Ministry of Education was that it is not culturally acceptable to teach sex explicitly in schools. On the other hand, population issues, family planning and human reproduction (anatomical and physiological aspects) are included. In addition, HIV/AIDS is included in science and biology topics for adolescent students. HIV/AIDS Policy and Strategy AIDS tends to be viewed as an external problem, and public understanding is still very limited. The Egypt National AIDS Programme Strategic Plan 2001-2005 identified youth as one of the priority areas. Adolescents' lack of knowledge about HIV/AIDS is a particular concern - one-quarter of older adolescent boys and one-third of older adolescent girls reported in the 1997 survey that they had no knowledge of the disease. UNFPA and IPPF Evaluation: Egypt Country Report 21 Constitutional rights of young people The Egyptian Constitution of 1971 includes a bill of rights, which guarantees a right to equality and to life. Health and education are basic rights of every citizen irrespective of gender and other distinctions. The Constitution also guarantees “the protection of adolescents and youth, and provides the conditions for the development of their capacities”. Egypt has ratified international rights conventions including: CEDAW, CRC, Goals of the World Summit for Children, ICPD and Beijing Platform for Action, although national level implementation has been slow. Egypt has indicated that some issues will need more time for implementation, especially those that have socio-cultural implications (e.g. the cultural acceptability of polygamy among Egyptian men). Furthermore, in the ICPD PoA, the GOE is reluctant to refer to the rights of the individual, preferring to refer to ‘couples’. The state protects the reproductive rights of working mothers, but no allowances are made for fathers. Laws affecting the reproductive rights of young people7 The Constitution explicitly named Islamic sharia as the primary source of law for the Egyptian state, although historically the modern legal system had developed according to the French model. There is a Muslim fundamentalist movement in Egypt, but at present it is not considered a major influence. In contrast to the “secular” civil and penal codes, the Personal Status Law, which organises matters of marriage, divorce, custody, and inheritance, are guided by the official interpretation of Islamic jurisprudence. Although different versions of the Personal Status Law apply to the country's main confessional groups, sharia is the most important since the majority of the population are Muslim. Young people’s reproductive rights are not explicitly addressed under the law. The age of 21 is the legal age of majority, when citizens can exercise full civil rights. However children may work in limited occupations at age 14, girls may marry at 16 and boys at 18. A religiously trained registrar concludes marriage contracts for Muslims in a process governed by a regulatory framework. If birth certificates or other official documents stating the date of birth are not available, a medical certificate with an estimated age must be issued by a health unit or social centre. Falsification of these medical certificates and of birth certificates are the primary means by which marriages of underage brides takes place in Egypt. In addition to supplying proof of identity, photos, and fingerprints, the parties to the marriage must declare that they are free of medical conditions that might justify the dissolution of the marriage (including impotence, insanity, and HIV/AIDS). One of the sharia's essential conditions for a valid marriage is the consent of both partners. The law does not penalise forced marriage explicitly, though a guardian who coerces a woman or girl to marry commits forgery, and could be punishable on this basis. Common law, secret, or urfi marriage is also practiced, recognised for the first time by the Personal Status Law of 2000. Urfi marriages can now be registered in police stations. This facilitates proof of paternity for wives who bear children from such marriages, although they are still denied alimony and other entitlements. Polygamy is a legally and religiously sanctioned right of Muslim men. A man must declare his marital status at the time of the writing of the marriage contract, and inform any existing wife/wives by registered letter. This cannot be used as a legitimate basis for divorce by the existing wife, although she may attempt to prove that her husband's marriage has caused her moral or material harm. If however, the new wife learns of her husband's existing wive(s) only after her marriage to him, she may be granted a judicial divorce since she was deceived. 7 For a detailed review of the legal context, see In-Country Study 1: Legal Review (presented as a separate volume). UNFPA and IPPF Evaluation: Egypt Country Report 22 Non-consensual marital intercourse is not considered a criminal offence, although Egyptian law does penalise rape. In fact, the sexual satisfaction of the partner is a duty placed by sharia on both husbands and wives, though this is only implicit in state law. The sharia specifies certain instances of disobedience in which a husband may resort to beating, the severity of which is laid out in detail by this law. The husband may be prosecuted under the law if he crosses the limit of "discipline", or if he inflicts permanent damage. Even so, a harsher penalty is dealt out by criminal law to women who batter their spouses. The Penal Code allows men light prison sentences for "honour crimes" such as the murder of adulterous wives. Women, on the other hand, may be sentenced to life with hard labour for murdering their unfaithful husbands. The same law stipulates that men be sentenced to 6 months in jail for committing adultery, and women to no more than 2 years. Adultery is not considered as such for men unless the act takes place in the marital domicile, whereas women may be tried for adultery committed anywhere. Until recently, only men alone were allowed to initiate divorce proceedings. Unless the wife's right of repudiation was stipulated by the marriage contract, men could end their marriages without pretext. Divorce may still be pronounced by husbands without witnesses, and is effective as long as it is not done in a moment of duress. The divorce is then registered through a ma'zoun8. The wife may be notified in writing, and does not have to be present at registration of the divorce. The Personal Status Law of 2000 allows women to initiate divorce with the understanding that she thereby forfeits her right to her deferred dowry and other benefits. Women may also seek judicial divorce if she can prove she has suffered severe harm and can no longer live with her husband (e.g. if the husband has a condition that prevents him from performing his marital (i.e. sexual) duties, if he does not support his wife financially, if he is imprisoned or abandons her for a period of several years, or if he maltreats her). Divorced mothers retain custody of children until the age of 10 for sons and 12 for daughters, when custody is transferred to the father. If she remarries, the mother may lose custody of her children prior to this time. Rape and sexual abuse of those under the age of 18, as with those in other age groups, is punishable by imprisonment, often with hard labour. However, the Penal Code contains no provisions specific to incest. Adultery is considered a crime by Egyptian law, and fornication, is condemned by the sharia. Consensual sexual relations with or among those under the age of 18 are penalised by article 269 of the Penal Code, though the penalty for female adolescents is harsher than males. Following a series of legal battles and a lengthy public debate triggered by the 1994 ICPD, female genital cutting (FGC) was banned in Egypt in 1997. However it is not yet punishable explicitly under the Penal Code and there is confusion among the public regarding the legality of the practice (see section 1.4). Various forms of contraception may be obtained over-the-counter in Egypt. Pharmacists and health care providers are free to supply contraception, and no restrictions are applied according to marital status or age. Abortion is illegal in Egypt, but this does not interfere with medical doctors' right to practice their profession, and physicians may perform abortion if the health of the mother necessitates it. Young People's Participation in National Policies and Programmes Egypt recognises that children and young people are the country’s greatest asset. This was demonstrated in the Presidential Declaration for the Second Decade for the Protection and Welfare of the Egyptian Child (2000-2010), with the National Council for Childhood and 8 A marriage official who is legally authorised to conclude Muslim marriages and divorces UNFPA and IPPF Evaluation: Egypt Country Report 23 Motherhood entrusted with the mandate to continue to translate this political commitment into action and investments. However, young people themselves have not yet been encouraged to participate in planning, implementing or monitoring these actions. A NCCSSD report underscores that participatory programmes are planned and prepared for the youth and not with them. Moreover, programmes are planned without genuine awareness of the needs and problems of the different categories of young people9. Under the Adolescent and Youth Strategy (see above), which was formulated by adults without the active participation of youth, political development of youth is emphasised. Piloting of youth parliaments to support the concept of positive participation, youth participation in conferences and youth training on politics and citizenship and developing leadership skills are defined as new strategies. 1.3 Sexual and Reproductive Behaviour Social and cultural attitudes towards young people's sexual activity, marriage, and fertility. There is a deeply held cultural condemnation of pre-marital sex (Population Council et al, 1997). Because marriage and procreation are of such central importance, preparation for married life is considered one of the most important aspects of growing to adulthood. However, Egyptian culture does not approve of extensive knowledge on sexuality, especially among unmarried young people, and even more so for unmarried young women. Most young people consulted in the FGDs considered it unthinkable that an unmarried person (especially a female) would try to access contraception. Women are universally expected to marry, most at a young age, and to start childbearing shortly after marriage. Most do not therefore seek family planning until after the first child. Most of the young participants in the FGDs thought the action of contraception was not against religion, but the idea of limiting your progeny to a defined number was considered by many participants as unethical. Whilst spacing of births is quite acceptable, only God determines the number of your children. Many put it, in brief, “Birth control is wrong but birth spacing is right”. Sexuality is not a topic for formal discussion among unmarried people. The National Survey of Adolescents (ASCE) survey did not collect information on the sexuality of adolescents because of the “obvious sensitivities in discussing this subject during family surveys”. The EDHS only interviews ever-married women. Age at marriage and age disparities The law forbids marriage under the age of 16 for girls and 18 for boys. However, among women of reproductive age, an estimated 14 % are married before the legal age of 16. The EDHS (2000) reports that there has been a marked decrease in girls marrying at young ages: the median age of first marriage among women aged 25-29 years was 20.8 years, compared to the median age at first marriage among women aged 45-49 years (18.1 years). The average age of boys at marriage is higher. Women frequently marry men considerably older than themselves - the National Adolescents Strategy (2001) reports that 70% of surveyed girls married husbands who were 10 or more years older. This increases the likelihood of substantial power differentials within marriage. Consanguineous marriages are also very common, from 29% in the Urban Governorates up to 50% in rural Upper Egypt. This is more likely to be the case for those married at 19 years or below. A UNICEF qualitative study with youth found that girls are often requested to marry a man preferred by her family. In 60% of adolescent marriages, the final decision regarding marriage rests with the girl's father. Negotiations regarding the marriage occur 9 Towards the implementation of the Convention of the Rights of the Child in Egypt. UNFPA and IPPF Evaluation: Egypt Country Report 24 between the bride's father and the groom, or the groom's father, and revolve around economics and compatibility. In the ASCE survey, girls favoured a later age at marriage for both sexes, but particularly for boys. Adolescent boys were more inclined to favour early marriage than girls. Approximately 16 percent of girls favour a spousal age difference greater than five years, compared to 5 percent of boys. Boys were also significantly more likely than girls to favour educational inequality between spouses. While neither boys nor girls had particularly progressive gender role attitudes, girls were significantly more likely to express less traditional attitudes. Girls’ and boys’ attitudes did not vary consistently and significantly by socioeconomic background. Knowledge, attitudes and practices of young people There is little data available regarding knowledge, attitude and practice of contraception by never-married young people, due to the sensitive nature of these questions in the Egyptian socio-cultural context. A survey conducted in 1995 by the Cairo Demographic Centre and Egyptian Family Planning Association found that knowledge about reproductive systems was very low, as the subject is only being taught to students of biology in the third secondary grade of school. The 1997 ASCE survey found that only 14 per cent of older adolescent boys (aged 16-19 years) and 5% of unmarried adolescent girls were aware of the condom as a contraceptive method. This, however, is not consistent with findings in the FGDs, where knowledge of all contraceptives was universal. They were perceived only for use by married couples. The role of condoms in prevention of STIs was rarely mentioned. Among ever- married young women aged 15-19, almost 100% have heard of a modern method of contraception (EDHS 2000). Knowledge of STIs was also poor, with only 10% of boys and 4% of girls being well informed about gonorrhoea, syphilis, and other Sexually Transmitted Diseases (STIs are now taught in the tenth grade at school). Knowledge of how HIV/AIDS is transmitted is also low. Despite their marital status, the reproductive knowledge levels among married adolescents are also quite low. Although they know about FP, only 20 percent of women can correctly identify the fertile period (2000 EDHS). Again, little is known about the sexual practices of young people, although the general feeling is that they are quite conservative. There is, however, some sporadic evidence suggesting that, with marriage age rising and young people facing a longer period between sexual maturity and marriage, sexual mores may be changing and pre-marital sexual contacts may be more common than in the past. In a study of four universities in Egypt, one- quarter of unmarried male students and three percent of female students reported having had sexual intercourse at least once10. The personal observation of one of the officers who conducted the ASCE survey was that premarital and extramarital sexual experiences are common among men (estimated about 25%) but almost non-existent among women. Because of the “culture of silence”, knowledge gained during adolescence is often fragmented and incomplete, and usually gained through friends or discreetly from reading or television. The 1997 National Survey of Adolescents found that the overwhelming majority of both boys and girls wanted more information in areas such as the physical maturation process, prevention of sexually-transmitted diseases, and pregnancy and childbirth. The context of getting the IEC message across is of extreme importance. There is very little information available from reliable media sources or the school curriculum. Of the young people who participated in the FGDs, some were happy with group discussion and seminars, which gave them the opportunity to discuss freely, to give and take, and embarrassing questions could be even be asked in writing. However, for others, the experience was 10 Preliminary results of a study conducted by El Zanati et al UNFPA and IPPF Evaluation: Egypt Country Report 25 frustrating. Speakers were not “professional”, time was short, some speakers were “in a hurry” doing just routine work and some even gave the impression that they were not convinced themselves of what they preach. 1.4 Priority Sexual and Reproductive Health Issues Facing Young People Early Marriage and Childbearing Strong cultural norms encourage girls to prove their fertility soon after marriage. The 2000 EDHS found 20% of 19 year olds had begun childbearing. Early childbearing is declining as girls stay in school longer and marry later, but early childbearing still constitutes an important health and survival threat to female adolescents, particularly in rural Upper Egypt where women are least likely to receive antenatal care, and births are least likely to be assisted by a trained health professional. The level of teenage fertility is strongly associated with rural residence (twice as high as in urban areas), women’s educational level and work status. The proportion of women age 15- 19 who are pregnant or who have already given birth decreases from about 17% among women with a less than primary education to 7% among women with at least a secondary education. Safe Motherhood and unsafe abortion To redress the fact that the majority of adolescent deliveries take place outside of a health facility and are not attended by a physician or a trained nurse or midwife, the Child Law of 1996 legislated that non-physicians may not attend deliveries for adolescents. The exceptions to this law are registered trained midwives or assistant midwives, who may assist in the childbirth of young mothers. Abortion is illegal in Egypt, and is punishable by imprisonment for both the woman and the practitioner. Despite the legal restriction, unsafe abortion is a problem, particularly for poor women. A study in an emergency obstetric unit in Mansoura found that one in every eight emergency admissions was the result of unsafe, induced abortion (Mashali, 2000). A representative survey of post-abortion cases in Egyptian hospitals shows that 8.5% of post- abortion patients are aged 15-19 years, and over 25% are aged 20-24 years (Huntingdon et al, 1998). Access to quality RH services Although 95 percent of the population now live within five kilometres of a health care facility, the health care system still falls short of MOHPs stated long-term goal of universal coverage of basic health and RH services. Public services are under-utilised, mainly because the quality of public health care, particularly at the peripheral level, is generally still rather low. Over 60 percent of all primary health visits take place in private sector facilities. Young people have access to general health services provided by a variety of agencies. However, they would not go to a health facility for either medical examination or consultation unless married or accompanied by one of their parents. Access to reproductive health care is restricted. It is culturally unacceptable for an unmarried girl or woman to enter a family planning (FP) clinic, and unmarried women are not expected to use family planning methods. Unmarried youth are encouraged to attend for premarital examinations, but these are medically oriented, and focused on exclusion of disease or other physical abnormalities Although marital status is a definite barrier to access to FP, age or gender was not perceived as a barrier by these young people. However, since the Egyptian culture puts almost all the UNFPA and IPPF Evaluation: Egypt Country Report 26 burden of family planning on women, none or very few men (including adolescents and youth) would go to a clinic for services. Even when they do, they will be accompanying their wives rather than going to get service themselves. Data collected in the ASCE survey show that when ill, 76% of young people use private practitioners, 35% the Health Insurance System, 49% the MOHP facilities, and 50% the School Health Insurance System (SHIS). 46% use two providers. The reason for not using the SHIS more widely was dissatisfaction with the service, often due to lack of a doctor when needed. Young people in the FGDs could not conceive of discussing reproductive health because of lack of privacy and confidentiality, and unsympathetic staff with neither the time nor skills. Although MOHP clinics were perceived as providing a good FP service, most expressed a preference for private health facilities for general and other RH services, despite the cost, which they perceived as reasonable11. Of the currently-married women surveyed in the EDHS (2000), 74% of women aged 15-19 knew a source of family planning services compared to 90% of 25-39 year olds. Almost 30% of ever-married 15-19 year-old young women have ever used a family planning method; less that 2% of these were traditional methods. Just over one in five currently-married 15-19 year old women currently use a modern method, with the IUD being the most popular method (EDHS 2000). Although married young people have been using existing health and RH services, youth RH needs for services have been promoted but have not yet been met by concrete youth RH services (see section 2, under 7CP). In Egypt, STIs are usually treated by either “Skin and Venereal specialists” or “Venereologists”. These types of specialists work in public health facilities at the tertiary level, private clinics, and university hospitals. However, patients suffering from STIs would only go when suffering from persistent pain, ulcer or discharge. Otherwise, a patient might be diagnosed late because of shyness or inaccessibility to the right health advice and service. The EDHS did not collect data on STIs. Gender-based violence According to EDHS 1995, 35% of wives have been beaten during their marriage. In almost all cases (approximately 96%) this beating was conducted by the husband. In the remainder of cases other persons, mainly the mother in law was the person responsible. Female Genital Cutting12 Female Genital Cutting (FGC) is a common practice in Egypt. 86% of female adolescents aged 13-19 are circumcised (Population Council 1997). The EDHS (2000) found 97% of married women of reproductive age were circumcised, and that the median age at the time of the circumcision for daughters is 10 years. Education and socio-economic status are important factors - 50% of girls with secondary schooling were circumcised, compared with 90% with incomplete schooling, 82% of urban girls compared with 94% of rural girls, and 75% high socio-economic compared with 91% low socio-economic class. Generally the parents make the decision There is recent evidence of change. The proportion of women who believe the practice should continue fell from 82% in 1995 to 75% in 2000, and the percentage of women who intend to have their daughters circumcised in the future decreased from 38% to 32% 11 All the FGDs were conducted in cities, although some participant lived in rural areas. Most were educated and single. 12 For consistency, Female Genital Mutilation (FGM) is referred to throughout as the report as female Genital Cutting UNFPA and IPPF Evaluation: Egypt Country Report 27 (Population Council 1997). Presumably, these changes are the result of efforts by the Ministry of Health and Population (MOHP) and NGOs to increase public recognition and discussion of FGC as a serious health and human rights issue. However, 90% of married women and 60% of never married girls who have already had FGC still believe it is necessary. FGC has deep roots in Egypt, and is practiced by Muslims and Christians alike: it is more rooted in tradition than in religion. It is undertaken for a number of reasons related to perceptions of ethics, sexuality, fertility, and maternal and child health. It persists because of beliefs that it is sanctioned by religion and tradition, that it will moderate female sexuality, make a girl eligible for marriage, and contribute to personal cleanliness or hygiene. The extent of this practice, and its condemnation as “female genital mutilation,” became a public issue during the 1994 International Conference on Population and Development (ICPD). The ICPD helped create an atmosphere in which support for FGC could be questioned openly. The 1995 EDHS was the first national-level survey to include questions on the practice of female circumcision. FGC was banned in Egypt in 1997, and this year the MOHP prohibited the practice in all hospitals, public and private clinics, or elsewhere by medical doctors and traditional midwives alike. However, the Egyptian medical community is not united in its views on female circumcision. The 2000 EDHS reports that 52% of circumcisions are performed by a doctor (mainly in private facilities), 9% by a trained nurse or midwife, and 32% by a traditional birth attendant. Certain public figures continue to endorse FGC. This, in combination with the series of contradictory decrees and policies, has led to confusion among the public regarding the legality of the practice, which is not yet explicitly punishable under the Penal Code. The MOHP, Ministry of Social Affairs (MOSA), donors, and many non-governmental organisations (NGO) are now working together to address FGC within their varied activities. UNFPA and IPPF Evaluation: Egypt Country Report 28 SECTION 2: THE STRATEGIC PRIORITIES OF THE COUNTRY PROGRAMMES 2.1 The Strategic Priorities of the UNFPA Country Programme 2.1.1 Relevance Overview of UNFPA assistance to Egypt before ICPD The first UNFPA Country Programme (CP) in Egypt (1971-1975) was exclusively focused on population reduction programmes through increased use of Family Planning (FP). This FP orientation continued though the 2CP and 3CP, and determined the spirit of assistance in statistics gathering, operational research, expansion of services and the training of staff. The 4CP focused on the further institutionalisation of MCH/FP services, but 13% of the budget was allocated to the Ministry of Education’s (MOE) population education programme. This was the only youth-oriented intervention before ICPD, and was focused almost exclusively on FP and the environment. The 4CP focused on the further institutionalisation of MCH/FP services, to which 75 % was allocated. UNFPA also gave 2% of its total budget to the Ministry of Social Affairs to strengthen empowerment strategies and implement activities influencing the decision making power of rural women. Compared with other women, those involved in income-generating activities were more likely to have a smaller family size, a higher demand for contraceptives, were more involved in community activities, and girls had greater chances to stay in school. The 4CP also dedicated 13% of its total budget to the MOE, whose population education programme had an impact on population awareness in the selected schools. The 4CP therefore indirectly influenced the reproductive well being of young people, namely students in the formal education system, and young women who fell within the target group 'women' or 'mothers' through activities it supported, though this was not articulated as such. UNFPA assistance to Egypt after ICPD There have been three CPs since ICPD (ICPD came in the middle of the 5CP). A summary of the programme budgets and sources of funds are shown in Table 1. Table 1: Sources of Funding for the 5th, 6th and 7th CPs (US$) CP Regular UNFPA sources Multi-bilateral sources Total 5th CP (1992-97) $10 million $10 million $20 million 6th CP (1998-2001) $14.4 million $3.6 million $18 million 7th CP (2002-2006) $10.5 million $7.5 million $18 million Sources: 5,6,7 CP documents The Fifth Country Programme (1992-97) The 5CP was designed and approved before the ICPD, and concentrated its central level assistance on strengthening the capacity of government bodies for data collection and analysis, and enhancing the technical capabilities in policy formulation and the planning, management, monitoring and evaluation of national population programmes. However, it did specifically include young people, as articulated in the following strategies: UNFPA and IPPF Evaluation: Egypt Country Report 29 IEC and advocacy § Assistance to the Supreme Council for Youth and Sport, as well as other “youth to youth” groups, to explore new ways to provide RH information and education to the age group 15 to 24, which constituted 18.5% of the population, § Assistance to the IEC sector to devise strategies to reach youth groups in Upper Egypt in the formal educational sector and community groups. MCH/FP § UNFPA assistance was to focus on quality and outreach care, to improve maternal and adolescent RH. Women, population and development § Support to programmes directed at young women on birth spacing and delayed age of marriage, § Support to activities increasing employment opportunities for young women for positions traditionally occupied by men, and, § To provide literacy programmes for young female school drop-outs. Special programmes § Assistance to programmes raising awareness among youth concerning the relationship between population and environment. The fact that this CP, with its explicit mention of young people and RH, was approved by the GOE was seen as a major step forward in Egypt. Other proposed strategies included young people by default as part of a general audience, or included topics that concerned youth. These included promotion of the mass media, especially television, for broadcasting RH messages including delayed age at marriage, safe motherhood and responsible parenthood, and involving men in FP and promotion of condom use. Four youth-focused projects were implemented (see Table 2), all designed before ICPD. Their objectives were to a limited extent consistent with the strategies outlined above. Three were education-related projects aimed at students and out-of-school youth. Table 2: Youth focused programmes and rights related topics in the 5CP Youth focused programmes Target group RH rights related topics Implementing agency Out-of–School Population Education Educators in out-of- school activities None or very limited National Population Council (NPC) Population Education in Universities Teaching staff & students None or very limited NPC Population Education in Primary, Secondary and Preparatory Schools In-service teachers None or very limited NPC Youth Leadership Development Project Facilitators and volunteers of youth- serving NGOs in 15 governorates Violence against women, family violence and gender CEDPA/ITRFP (EFPA partner) Following ICPD, and the GOEs and UNFPAs Country Assessment, the FP orientation shifted gradually in some respects towards the ICPD-POA. The intention was to broaden the UNFPA and IPPF Evaluation: Egypt Country Report 30 concept of integrated reproductive health, support NGOs, and to involve youth. This explicit targeting of youth was also aimed at overcoming the negative media coverage on the ICPD shortly after the conference (see section 4). However, no significant changes were made in three of the four projects. The content of the IEC programmes for in and out-of-school youth remained limited to family planning, population growth and environment issues, with minimal reference to the broader range of RH and rights. The “Youth Leadership Development Project” was, however, modified to ensure that young people were more involved in the project design and management (see later in this section). The focus was also widened from increasing the knowledge and skills of young people in relation to population and development, to starting to address the relationship between youth needs and the ICPD POA. During implementation of the CP, other programmes also addressed youth related issues. Under the RH services sub-programme, UNFPA supported drafting of the National Adolescent Strategy: Towards Improving the Outcome of Adolescence by the Population and Family Planning Sector (MOHP). This included a chapter on reproductive health, which, however, distinguished between the never-married adolescents, who need to be educated on all RH matters, and the married adolescents who also needed guidance and provision of RH services (see section 1.2). It also acknowledged the cultural barriers to including issues of a more sensitive nature into school curricula. However, it was seen as a breakthrough because it was the first time that attention had been drawn to the RH health of adolescents in Egypt, and provided the basis for UNFPA to start lobbying for a comprehensive adolescent RH initiative. The focus on young people was also extended to other projects. For example, the Population and Development Strategy (PDS) sub-programme supported the National Centre for Population and Development to train and mobilise young volunteers for data collection. In summary, the strategic focus on RH for youth in the 5CP document was relevant, but remained mainly good intentions as the strategies were only partly implemented. The Sixth Country Programme (1998-2001) UNFPA's ultimate assistance goals were to contribute to an improved RH of all Egyptians, to a reduction of gender disparities, and to the achievement of sustained socio-economic development. Specific objectives to be achieved within the time-span of this CP generally reflected the ICPD, but did not include any explicit focus on young people: § Improve quality and scope of RH, including FP and sexual health in selected areas with population indicators lower than the national average § Enhance IEC capacity addressing RH in general and FGC in particular § Strengthen capacity at MOHP in population information and co-ordination mechanisms § Empower women in RH, education and economic fields (no specific age groups were mentioned § Accelerate follow-up of ICPD recommendations by the GOE, NGOs and donors. The document states that the programme would be undertaken in accordance with the principles and the objectives of the ICPDs PoA. However, the document does not reflect any major changes in shift towards a rights based approach to sexual and reproductive health of youth. The main shifts in the strategy of the 6CP were to integrate FP into RH, and to move away from strengthening institutions at the central level to a concentration on disadvantaged population groups and specific geographical regions. UNFPA and IPPF Evaluation: Egypt Country Report 31 Under the 6CP, 4 projects and one component of a PDS project addressed youth (see table 3). Table 3: Programmes with a youth component in the 6CP Sub-programme Target group Rights related topics Implementing agency Advocacy Component Project Parliamentarians, media personnel, religious leaders, women, youth groups and NGOs Early marriage, FGC, Violence against women, Access to information on RH issues MOHP Pilot implementation and Evaluation of RH Framework PHC providers and ever married women in focal areas Access to quality RH services, informed decision making by women. SRHR/ Reproductive Health Working Group (RHWG) Expanded Use of the RH Framework PHC providers and ever married women Access to RH and IEC RHS/RHWG Integration of Youth RH into Boy Scouts & Girl Guides Education and Development (Reg. Project) Girls and young women Access to RH and culturally appropriate IEC World Organisation of the Scout Movement, Family Health international Youth Awareness Training (component of PDS sub-programme) Youth leaders in 25 governorates Improvement of women’s status and adolescent’s and youth strategy Ministry of Youth The nationwide advocacy programme was executed by the MOHP and addressed sensitive RH issues among religious leaders, a wide range of media professionals, decision makers and parliamentarians. The promotion of ICPD goals (in general) and elimination of FGC were major focal areas. It also aimed to co-ordinate efforts to influence attitudes of youth on gender issues and to increase male involvement in reproductive health. Activities included anthropological studies on socio-economic conditions, gender disparities, and FGC, preparation of advocacy kits for parliamentarians and media leaders; and training of media as a key channel for disseminating messages regarding gender issues and elimination of FGM. The status of women and other gender issues were also emphasised, but not with any special concentration on youth. The sub-national approach aimed to contribute to expanded utilisation of integrated quality RH services with special attention to women and youth living in the selected priority focus areas. However, implementation did not explicitly focus on youth (see section 5). Local campaigns on the harmful effects of FGC were also launched on the basis of socio-cultural study outcomes. The Youth Awareness Training Programme was implemented in twenty governorates with high population density and low prevalence of contraceptive use. It enhanced the capacities of selected youth leaders, representing the different youth centres at the governorate level, in how to deal with sensitive population, development and gender issues. The content of the training included the population problem, FP in RH, religious views regarding various population and FP issues, including secret marriage, and the role of women in development. UNFPA and IPPF Evaluation: Egypt Country Report 32 Youth were trained in how to "translate" the questions in the socio-economic disparities survey into understandable local languages. It was the first time that a PDS programme recruited youth volunteers in population activities. The development of the new National Population and RH Strategy, which addresses identifies adolescents and youth as a group with special needs (see section 1.2) was also supported as part of the PDS sub-programme. The Seventh Country Programme (2002-2006) Young people have become a much more explicit focus in the 7CP. The main goal is to contribute to achieving an appropriate balance between population and development. UNFPA will play an increasing role in policy dialogue and increase its focus on neglected groups, including adolescents and youth, who will be the main focus of the reproductive health sub-programme. The programme will: · promote awareness among policy makers and within the community and create partnerships with relevant institutions, in particular civil society organisations, to effectively reach young people · provide support for developing culturally sensitive educational materials and messages for young people, utilising innovative approaches to reach in-school and out-of-school young people, involving parents, teachers, and community and youth leaders. · provide support to MOHP and to relevant NGOs to create a youth-friendly environment at service delivery points, including sensitive and respectful counselling for young people and outreach support · provide increased awareness of reproductive health and rights and the elimination of gender-based violence, particularly at the community level. Special attention would be given to addressing girls education, early marriage, male involvement, female circumcision and domestic violence. At the time of the evaluation, UNFPA and its partners were in the process of translating the 7CP recommendations into concrete projects. No project documents could be reviewed, and therefore most of the following is based on discussions with UNFPA staff, which involved consultants and the CP document and the UNFPA presentation during the stakeholders' meeting. The proposed youth-focused projects are summarised in Table 4. Table 4: Proposed youth-focused programmes and rights related topics in the 7CP Youth focused programmes Target group Rights related topics Implementing agency Support to RH Services at MOHP (with focus on adolescents and youth) Women and youth Women’s access to IEC and holistic services EFPA Integrated Teaching at Medical Schools Medical students Students’ Access to RH information National Council for Childhood and Motherhood (NCCM) Meeting the RH needs of Adolescents Adolescents and youth in 4 governorates Adolescents and youth access to holistic youth-friendly services EFPA Support to the Year of the Egyptian Girl Child. Rights of the Child NCCM UNFPA and IPPF Evaluation: Egypt Country Report 33 UNFPA intends to support implementation of the new National Population and Reproductive Health Strategy (NPRHS) (see section 1.2), which explicitly (and in some components implicitly) includes adolescents and youth. It has prioritised the provision of technical support to government and NGOs to address youth-friendly services, girls’ education, early marriage, male involvement, female circumcision and domestic violence. This CP will operationalise for the first time a holistic RH package providing information, education and services for young people. This strategic shift towards adolescents and youth is expressed in the budget allocation. Meeting the RH Needs of Adolescents and Youth has been allocated 75% of the budget for the RH sub-programme and 33 % of the total UNFPA funding. Determination of the CP focus and balance of priorities The CPs have been developed within the context of the national population policies, taking into account the inputs from other partners and UNFPA’s mandate, organisational mission and objectives and comparative advantages. The 5CP and 6CP were designed in the basis of evaluation reports and thematic evaluations, and the outcomes of the Programme Review and Strategy Development (PRSD) processes (a joint UNFPA and GOE exercise). During this process discussions were held with the National Population Council, Governmental and non-governmental agencies, UN organisations and relevant multi-bilateral donor organisations. The PRSD process has now been replaced by a Common Country Assessment (CCA), initiated by the United Nations Development Assistance Programme (UNDAF) (see section 3.1.1). During this process it was recognised by all partners that adolescents and youth were a neglected target group, and deserved higher priority. UNFPA can take some credit for increasing the focus on RH for young people, and laying the foundations for this acceptance. However, it is not clear that priorities and strategies have been objectively determined by a rigorous evidence base. Although some socio-cultural research has been undertaken, research findings have not always been used effectively in developing future priorities and directions. This is partly due to lack of staff skilled in using population data and other research findings for programme planning and monitoring. The use of evaluation findings to feed into strategy and planning is discussed in section 3.1.3. Proportion of the CP devoted to policy development, service strengthening and IEC The proportion of the CPs’ budgets allocated to sub-programmes is shown in table 5. Table 5: The Allocations of Funding by Sub-programmes under the 5, 6, 7 CPs Country Programme and sub-programmes Budget (actual expenditure) 7th CP Reproductive Health Population and Development Strategy Umbrella 58% 39% 3% 6th CP RH PDS Advocacy Umbrella 50% (66%) 24% (8%) 22% (21%) 4% (5%) 5th CP* MCH&FP IEC Data Collection & Analysis Population Policy & Capacity Building Special Reserve 60% (37% 10% (27%) 10% (17%) 13% (19%) 4% 4% Source: UNFPA office, Egypt UNFPA and IPPF Evaluation: Egypt Country Report 34 (* The categories of the projects by Sub-Programme were not clear in the 5th CP) Data is not available on the proportion of the 5th and 6th CP that went to youth related activities. However, as stated above, the Responding to RH needs of Adolescents project will receive 75% of the RH budget and 33.3 % of the total UNFPA budget. UNFPA’s Role in Sectoral and Sub-Sectoral Programmes UNFPA played, and still plays, an important role in the health sector in the areas of RH, PDS, advocacy and IEC. Since the FP-concentrated CP cycles, including the 5th (1992-1997), UNFPA has been influential in introducing ICPD into programmes of the MOHP, donors, NGOs and other private institutions. The strategic role of UNFPA in these sectors became more distinct in the 5CP, wherein UNFPA supported inter-sectoral efforts to alleviate poverty, and promoted a more comprehensive view of women’s role in the development process. This continued in the 6 and 7 CP. The Programme Review of the 6 CP acknowledges that UNFPA advocacy and assistance to donor co-ordination in the population sector resulted in increased support from other organisations to youth RH issues, in strengthening the capacities of the NGOs and in launching FGC campaigns. This explicit targeting of youth was also aimed at overcoming the negative media coverage of ICPD shortly after the conference. Health Sector Reform is still in an early stage in Egypt, and the pace of implementation is slow. UNFPA is involved "from a programmatic point of view" as far as integration of RH into the PHC services and quality of care. According to the 7CP, "health sector reform is paving the way for an integrated family practice approach and aims to provide easy access to affordable basic health services to all Egyptians". The ongoing HSR is seen as providing “an effective entry point for (UNFPA) policy interventions". The effectiveness of such an entry point will very much depend on the success/efficiency of the HSR process. According to UNFPA staff, much remains to be seen. It would appear that UNFPA is playing a passive role in other aspects of the reform. Supporting this reform, UNFPA has promoted development of a model for integrating RH services in PHC services. The model appears to be highly effective, and has set the tone for forthcoming policies (Section 5). The PDS programme under the 6CP (1998-2002) might not have been successful with regard to capacity development, but the 11 strategies for the NPRHS proposed through the UNFPA-supported work, including the Adolescent and Youth Strategy, have recently been accepted by the MOHP. This is perceived by stakeholders as a ”major breakthrough”. Addressing the Diverse Needs of Young People Awareness about the diverse needs of sub-groups of youth has been very limited until now, and the CO has not sufficiently accounted for the unique needs that characterise each sub- group among 10-24 year-old Egyptians, particularly males or the unmarried. Diversity was seen in terms of Upper and Lower Egypt and urban/rural and educated and non-educated, but what that implied for RH and rights was not well articulated. Thus at project level, though efforts were made to reach young farmers, and youths in school and university settings, these efforts were more related to reaching different target groups with the same information rather than assessing potential differences in need among these groups. One example is the 5CP’s “Population Education” projects, which were identical in content but launched in different settings for different target groups. An exception was the “Youth Leadership Development Project” which was developed with youth to respond to their identified needs (see section 5). UNFPA and IPPF Evaluation: Egypt Country Report 35 There have been some empirical efforts to investigate disparities among young people. UNFPA supported the Study on Adolescents in Selected Schools in Cairo and Giza13. However, although staff may understand research findings they are not always skilled in translating evidence into appropriate strategies or recommendations. Even then, the implementers may not be able/or willing to put these into practice. There has been an underlying assumption that organisations familiar with working with youth are qualified to understand and respond to youth’s RH needs. However, this is not necessarily borne out in practice. During 5CP and 6CP, UNFPA attempted to address young people’s needs through collaboration with various agencies working with youth, e.g. Ministry of Youth, Ministry of Agriculture, Association for Boy Scouts and Girl Guides. Most organisations employed top- down approaches to youth - for example, needs assessment studies were developed without the involvement of youth or were not conducted at all. If they were carried out, the main interest was related to knowledge indicators while indicators measuring (life) skills (e.g. how to ask RH questions/discuss RH with peers and parents) were limited. The limited number of youth institutions in Egypt has also been a hindrance. Under the 7CP, there is a more explicit recognition of the diversity of needs. Married and unmarried youth will be distinguished, which is perceived as a significant move forward (although only if it means that RH services will be provided for unmarried youth, which is yet to be seen). More attention will be paid to gender-related youth issues, and geographic disparities. Client oriented and gender sensitive RH services will be promoted and integrated in IEC approaches and in the human resource development plan. UNFPA staff perceive that young adolescents (10-14) require RH knowledge, whereas those aged 15-25 need services. Appropriate responses to these needs for RH services are still in the process of being developed and the concept of what youth-friendly responses imply, and how health care providers and other disciplines can provide these, are currently being explored under the 7CP (see section 5.1). The same applies to the ongoing endorsement of the involvement of men and responses to male RH needs. The 7CP plans to support efforts to determine the socio-cultural constraints associated with male participation. Involvement of Young People Although young people have been the target group for many of the projects, their involvement has generally been limited to that of a passive recipient of project benefits. Their involvement in policy development, project design and management has been minimal. The only project that explicitly included youth as active members in project design, implementation and monitoring was the Youth Leadership Development project in the 5CP. This project originally aimed at increasing the knowledge and skills of 1200 youth in 15 governorates in relation to population and development. Initially, a limited role for youth was envisioned, and young people were not involved in the design. After ICPD, an NGO (the Youth Association for Population and Development), whose members worked as volunteers at the ICPD, lobbied for a more expanded role. The project was modified accordingly and became a truly youth-owned endeavour (see section 6.1.1). However, only about 40% of the facilitators were female, because they faced resistance to participation from their parents. According to Institute for Training and Research in Family Planning (ITRFP) staff, this was because they had to travel and spend long periods of time away from home. Young volunteers were exposed to new training and were perceived as useful assistants in data collection. However, according to the youth NGO, UNFPA never shared with them the findings of the evaluation. The “Advocacy Component Project” mobilised young people in the audience for a theatre play, and young volunteers played key roles (see section 6). In the Youth Awareness Project of the 6CP, the MOHP worked closely with three other ministries to implement integrated 13 UNFPA copy of Adolescent Health: Product Details. UNFPA and IPPF Evaluation: Egypt Country Report 36 population awareness activities (the Ministries of Agriculture, Education, and Youth). In the Ministry of Youth component, a core group of three people (one young male, one young female and a supervisor), was formed at the youth centre level for the awareness and educational interventions directed at youth. They were trained in FP, RH and gender roles. A study was undertaken with the assistance of local youth volunteers, who benefited from communication (interview) and computer training. Other youth oriented projects involved youth as peer trainers, but not in design or monitoring. Overall, opportunities for involving young people in national policy and strategy development have been missed. For example, although the Adolescent and Youth strategy of the new National Population and RH Strategy was based on findings from the adolescent survey, young people have not been involved in the further development of the strategy. 2.1.2 UNFPA Integration of Rights UNFPA recognises, and in several projects implicitly addresses, the key reproductive health and rights issues in the Egyptian context, but the term “rights” was not explicitly used until the latest 7CP. However, rights have generally been implied rather than explicitly stated, and even the 7CP documents do not reflect any major shift to a rights based approach. None of the three CP documents provides a clear definition of the concept of RH rights in the Egyptian context, or of what it means in terms of operationalisation. The CPs do, however, address the economic and socio-cultural factors influencing young people’s RH and Rights, such as illiteracy, poverty, lack of women‘s decision-making power, early marriage and harmful practices (FGC). Some of the 5 and 6CP programmes supported by UNFPA implicitly included rights-related topics, such as youth’s access to SRH information and RH services, awareness-raising on RH, self-determination, and promoting rights related to attaining the highest standard of sexual and reproductive health (see section 5 and 6). Rights issues related to young people in family violence and gender equity, early marriage, and FGC were also integrated in various sub-programmes and projects, and UNFPA has been very active in advocacy in these areas. Gender-related rights of young people are not specifically mentioned, but gender issues are addressed in all three CPs. UNFPA informants feel that gender-based violence needs urgent tackling but that NGOs should play the most strategic role as they have more “freedom” to express their concerns in public (see section 1). UNFPA staff are reluctant to talk in a straightforward manner about rights, or to aggressively push the concept, as they feel that in the Egyptian culture this might produce difficulties, upset counterparts and prove counterproductive (see section 3). They are careful not to up- set politicians and others they have to work with. For example, the name of the project “Advocacy on RH and Rights” was revised to “Advocacy component project”. This more neutral name facilitated the process of acceptance of the project among the authorities. A further problem in Egypt is that although the RH rights of a couple may be acceptable, there is a reluctance to accept the concept of the RH rights of an individual (see section 1.2). This is linked to cultural unacceptability of sexual relationships before or outside of marriage. Rather than addressing rights explicitly in a potentially confrontational way, UNFPA has taken a “softy-softly” approach to introduce the concept and implicitly address rights issues at the level of project implementation. They have attempted to translate some rights into real life circumstances that audiences can easily identify with (such as early marriage or female school dropout). The same applies to the television programmes developed under the same project (see section 6). UNFPA and IPPF Evaluation: Egypt Country Report 37 2.1.3 UNFPA Sustainability of Youth programmes In general, there is strong partnership and sense of ownership by the government in UNFPA supported sub-programmes (Joint Review 2000), which contributes towards sustainability. However, overall there has been insufficient attention paid to the financial sustainability of project activities at the design stage. This was the case for the “Youth Leadership Development Project. However, sustainable outputs of the “Youth Leadership Development” programme include the manual developed, which was distributed to youth facilitators as well as other organisations, and active cadres of youth leaders (section 6.1.6) During review of the 6CP, it was realised that the PDS intervention relied too much on the support of external consultants and therefore its contribution towards building sustainable capacity within the MOHP was extremely limited. This will be taken into account in the 7CP. The review also concluded that NGO capacity was enhanced during implementation of the previous CP and that NGOs contributed to the implementation of the recommendations of the ICPD and ICPD+5. However, “the modality adopted was not sustainable” as NGOs wanted to continue with the successful projects but were not eager to share their pilot model with the Government as was the case of the “Youth Leadership Development Project”. 2.2. The Strategic Priorities of the IPPF/EFPA Country Programme 2.2.1 Relevance Historical Overview The Egyptian Family Planning Association (EFPA) originated in 1958 as the Association of Population Studies. It was the first voluntary association in the field of population and family planning in the Arab World and Africa, and the pioneer and main provider of family planning activities in Egypt until the Ministry of Health launched its first national programme in 1967. EFPA focused solely on family planning until 1988 when, with USAID and Dutch financial and technical assistance, it became involved in wider reproductive health related projects. The EFPA has been affiliated to the IPPF since 1965. In 1992, its name changed to the Egyptian Family Planning Association. The EFPA has a central office located in Cairo and 25 member Family Planning Associations (FPA) in 25 governorates (only one governorate, South Sinai, is not represented). EFPA clinic services are provided in three different settings: 1. Clinics directly sponsored and managed by EFPA. There are 3 types of clinics, which fall under this category: model clinics, upgraded clinics and regular clinics. 2. EFPA affiliated FPA clinics, which are only partially controlled by EFPA management. 3. Clinical Services Improvement (CSI) clinics, funded by USAID, government and IPPF. These three types of clinics have different management arrangements and financial systems, and their supervision and control from the central management is considerably different (see section 3.2). The EFPA established an Institute for Training and Research in Family Planning (ITRFP) in Alexandria in 1972. This was the first institute in the Middle East and North Africa providing specialised training in the field of population and family planning. It has since become involved in training for reproductive health and rights, and was involved in some of the youth UNFPA and IPPF Evaluation: Egypt Country Report 38 programmes implemented by EFPA. The organisational linkages are discussed in section 3.2.1. The Strategic Priorities and Objectives of the EFPA National Programme After the ICPD, the main shift that has taken place is from a mainly FP focus to a more comprehensive reproductive health focus. The FPA model clinics have expanded their range of services to include pregnancy follow-up, and premarital examinations. The CSI clinics provide comprehensive services, including FP and quality counselling, gynaecology, pre- marital, infertility, and menopause. The Alexandria clinic also provides general health services, including a dental clinic, internal medicine/general practitioner, and dietician. This clinic profile has been used in several CSI clinics, as variety of services attracts more clients and possesses more potential for income generation. To a lesser extent there has been a shift towards advocacy and women’s empowerment and youth, manifest in several projects funded by IPPF and others. The advocacy projects addressed issues as diverse as women’s rights, FGC, AIDS prevention and STIs, infertility and violence against women. EFPA has worked with youth as a separate target group since 1994. During the period 1995-2002, EFPA had three projects aimed at young people: 1. The “Youth to Youth for RH support” project (1994-99), funded by UNFPA, implemented in all 25 governorates with EFPA offices, was aimed specifically at increasing awareness of youth leaders (age between 15-25) in the field of SRH to help in future awareness raising activities with other youth in their own communities. 2. The “Female Youth Participation” Project (1996-2000), funded by USAID and CEDPA, aimed at empowering female youth (15 to 20 years old) through education and livelihood skills. RH information was included. It aimed at increasing the knowledge and skills of women leaders at the local level to support female youth and to participate in project development and monitoring. 3. “Youth Leadership Development Project”, funded by UNFPA in the 5CP (see section 2.1). Two other projects also conducted activities that are relevant to youth, the Agriculture Extension Project implemented by the Ministry of Agriculture and one implemented with the Ministry of Education. The first one involved farmers in FP/RH community awareness activities, extending project beneficiaries to those who are not included under other organisational structures. Most of these farmers are young. A further project in Assuit on FGC with a focus on young people was funded by UNICEF. However, all these projects focused in advocacy and information for RH. RH services for youth have not been seen as a priority until recently. Youth have however been included in all EFPA projects by default, and as part of the general (married) population for the provision of family planning and reproductive health services in FPA clinics. Until recently the EFPA did not have a strategic mission or vision. The new EFPA management structure has now developed mission and vision statements, which address the underserved groups and issues. The mission statement states that “EFPA complements the role of the public and private sector in improving the quality of life and implementing the objectives of the National Population Policy through the provision of high quality RH information, education and services in response to the needs of underserved groups”. EFPA vision entails that it will seek to provide a standardised quality package of RH information, education and services in all EFPA service delivery centres. EFPA aims to improve access and respond to the needs of those who face obstacles related to socio-economic, geographical, cultural and other issues. UNFPA and IPPF Evaluation: Egypt Country Report 39 EFPAs strategic plan for 2003-2007 has three Strategic Objectives: 1. Increase access to integrated high quality RH services to underserved groups especially adolescents and youth. 2. Increase access to high quality RH information and education to targeted groups specially adolescents and youth. 3. Establish an effective and efficient management system at the central and governorate levels. Specific objectives in relation to adolescents include: 1. Identifying RH needs of youth. 2. Promoting youth reproductive rights. 3. Developing a comprehensive package of RH information and services to youth. 4. Providing high quality RH information and services to youth. 5. Developing a system for monitoring, evaluating and follow-up the youth programme. Clear efforts have been made in the recent Strategic Plan to integrate the concept of young people’s reproductive health and rights into the current portfolio of projects and to fit projects within an overall strategic framework which prioritises young people. Project approaches include components to address a range of priority issues, including gender related needs and rights-based issues through advocacy and leadership training of both male and female youth. EFPA is planning to implement “Meeting adolescents RH needs Project” funded by UNFPA in four governorates (Dakahleya, Alexandria, Qualiubya and Menufeya) with a total budget of US $366.412. New initiatives, such as a hotline and web site for youth are also planned. Although at the moment not all of these initiatives are specifically for SRHR, there is potential to utilise them for information sharing and dissemination. Although EFPA intends to target youth, it is noteworthy that none of the FPA branches met had plans to work with youth RH issues. How priorities were determined EFPA has made some efforts to implement evidence based programming (see section 6.2), and to respond to expressed needs of clients. It is not clear how priorities have been determined by the EFPA and its branches. Overall, there does not seem to have been a strategic approach to planning services or projects. Programmes would appear to have developed incrementally. However, it would appear that priorities are also determined to some extent by the need to survive financially. Cost recovery, or at least partial recovery, seems to influence the range of services that are provided, the cost and the target groups. The priorities of EFPA are also probably influenced by the availability of funds for specific projects, and by the priorities (political and otherwise) of funders, as is often the case with NGOs. IPPF budget allocations to EFPA The following table presents the funds allocated by IPPF to EFPA for various activities during the period 1996 to 2002, in Egyptian Pounds, and their corresponding percentage of the total budget. UNFPA and IPPF Evaluation: Egypt Country Report 40 Table 4: IPPF budget allocations to sub-programmes, 1996 - 2002 Budget in Egyptian Pounds (percentage of the budget) (US$ exchange rates fluctuated dramatically, but on average were US$1=3.5LE) Service Strengthening Advocacy Youth Projects Other projects Salaries, admin. cap. Building Total 1996 378,380 (18.4) 215,230 (10.5) 118,370 (5.7) 315.000 (15.4) 1,031,921 (50) 2,058,901 1997 539,781 (26) 163,363 (7.9) 151,718 (7.3) 208,581 (10.2) 1,005,117 (48.6) 2,068,560 1998 539,870 (26) 101,518 (4.9) 151,718 (7.4) 270,083 (13.2) 996,037 (48.5) 2,059,253 1999 689,200 (31.5) 74,525 (3.4) 69,480 (3.2) 148,022 (6.8) 1,205,188 (55.1) 2,186,415 2000 125,000 (8.2) 0 0 0 1,400,285 (91.8) 1,525,285 2001 0 0 0 0 2,190,092 (100) 2,190,092 2002 1,510,834 (27.2) 0 0 105,000 (3.2) 1,590,300 (49.6) 3,206,134 Source: Management Information System, EFPA In 2000, 2001 and 2002, the IPPF stopped financing women, men and youth oriented projects. According to the Regional IPPF office, one of the reasons for withholding the grant was to review its approach in the light of evolved knowledge and best practice available in the region. Following the review, a new managerial structure has been set up to ensure efficient project implementation. The non-allocated funds were directed in 2002 to establishing a new central office for EFPA. The total IPPF budget for IPPF/EFPA Egypt for the year 2003 is LE 2.902.553, of which LE 500.461 (17%) are allocated to RH activities focusing on advocacy and youth. EFPAs strategic role influencing and implementing RH programmes The EFPA was the pioneer, not only in Egypt but in the Arab region, in providing FP services. As the sole provider for many years, it had a strategic niche in the field of RH. However, as FP services have become more widely available and integrated more comprehensively into a broader range of RH service and PHC in general, it has lost this strategic niche. Its strategic role at national level appears to have diminished in favour of its role as a service provider, with some advocacy and information activities. It is perceived, however, to have played a key role in promoting the status of women and awareness raising amongst girls before marriage, which has been recognised by the Egyptian Parliament. Overall, the EFPA is viewed as a key player in implementation but not a strategic one. It is perceived as responding to the interests of different Ministries rather than providing a clear, articulate and distinct voice from outside government structure. At governorate level, however, it appears that FPAs still plays a significant leadership role. They are well connected to a broad base government institutions, universities, other NGOs and development associations. In terms of implementation of the RH programme, the EFPA has almost nation-wide coverage (EFPA branches are located in 25 governorates of the 26), but does not serve as many people as the MOHP, which has more than 4000 FP/RH clinics all over the country nation-wide. FPA clinics are perceived by clients as providing better quality services than the UNFPA and IPPF Evaluation: Egypt Country Report 41 MOHP clinics, and usually serve middle class married women, frequently urban, who can afford to pay for services. In some places they have provided the option of higher quality services for those who can afford them. Elsewhere, they are filling a gap in service provision, for example, populations in areas deprived of MOHP services and geographically distant, or difficult areas in rural or slum urban areas. There is some variation in the cost of services, depending on the socioeconomic standard of the local community, but everyone is expected to pay. However, the EFPA has not yet shown that it can take up a leading role in youth projects. Responding to the diversity of needs of young people EFPA has made some efforts in its specific youth projects to respond to the diversity of information needs of young people (see section 6.2). Frequently however, these have been relatively well-educated young people, and there has been little systematic attention to identifying the different sub-groups and their needs. The core RH services have not made any attempt to respond to the needs of young people as a group, especially not the unmarried, except for pre-marital examinations (see section 5.2). Youth have generally been treated as a homogenous group, although gender issues have been addressed in most training programmes. Involvement of young people There have been no explicit attempts to involve young people in identifying and articulating their needs and rights in relation to policy and legislative reform. Participation of youth in project implementation has been encouraged, for example in outreach work, and as peer educators, and to a lesser extent in the design of programmes (see section 6.2). To date there has been no involvement of youth on the EFPA Board, although this is about to be rectified (see section 3.2). EFPA staff admitted that they need to acknowledge the power of youth in planning and decision making phases of their activities. 2.2.2 EFPA Integration of Rights EFPA has explicitly addressed rights in several publications (see section 6.2.2) and rights have been included in the content of outreach programmes aimed at informing village women (including young women) on contraceptives and spacing of children. A drawing competition was held among youth on rights issues. Campaigns have sought to raise awareness about FP for youth. EFPA have made efforts to identify/define reproductive rights in relation to some areas of interest like FGC, early marriage and family planning, and supported activities to facilitate the exercise of these rights in the fields of family planning and FGC. On the other hand, some RH aspects have not been given enough attention namely violence, sex education and strong male involvement and support. The new vision of EFPA mentions that it will particularly promote adolescent and youth reproductive rights through the provision of information and, as appropriate, RH care. However the three strategic objectives do not include any mention of rights (see section 2.2.1). 2.2.3 EFPA Sustainability The main sources of funds for EFPA and its affiliates have been the IPPF, USAID, the GOEs Social Fund for Development and the USAID funded NGO Service Centre. With the exception of IPPF, which provides funds that serve the overall organisation, the other funding agencies usually direct their funds to specific time-bound projects and activities that are frequently located in certain geographical locations and not at the national level. Regular predictable funding arrangements are lacking, which makes long term strategic and UNFPA and IPPF Evaluation: Egypt Country Report 42 operational planning problematical. There has been no dependable funding source for youth-oriented programmes. During the period of 1999-2002, no IPPF budget was allocated for advocacy, youth or other projects. This affected many of the branch FPAs activities (such as seminars and home visits by social workers and local health promoters), which have been reduced or eliminated entirely in the last two years. Diversification of funding sources has been one of EFPAs management strategies for sustainability, but some branches have had more success than others. Individual EFPA branches can, and some do seek funding for specific projects on their own initiative as autonomous FPAs, but many still rely on EFPA for a great deal of their funding. All interviewed branch FPAs reported a constriction of these funds in recent years, though to different degrees. None of the branch offices’ staff could elaborate on the criteria for allocation of funds from the EFPA to branch offices, nor did they know the reasons why IPPF resources have dwindled recently. Some clinics (but not the CSI) use revenues from service provision to subsidise non-income generating services such as IEC for youth. However this does not appear to be a general policy, or an explicitly articulated strategy (see also section 5.2). Sustainability of services generally, and thus the ability to cross subsidise advocacy and IEC activities, is now compromised in some clinics by the recent improvement in quality of services in MOHP clinics. In areas where both agencies serve the same population, this has resulted in competition from the low cost services, and declining utilisation of FPA clinics. Some branches have demonstrated capacity and initiative in responding to this, by diversifying services, cutting down on staff14 or accessing funds from new sources. For example, the Minya staff intend to shift away from FP service provision to capacity building, advocacy, and awareness-raising activities. It currently gains revenue from the provision of RH training for volunteers and promoters in other projects. This is an efficient use of existing resources and structures, and enhances their sustainability. Some branch FPAs have tried relocating clinics to more accessible locations, expanded their range of services, or have proposed to the MOHP that they utilise one another’s' clinics and health caravans, etc. Others have formed pragmatic partnerships with other NGOs (CDAs and Youth Centres) for financial reasons, usually to utilise their facilities, for both clinics and the Youth to Youth project. Personal relations with doctors and lecturers also facilitated the continuation of activities given the limited resources. Other braches have shown little initiative in accessing funds. CSI is mainly funded by USAID and IPPF, and currently recovers 40% of their overall cost. However, some clinics may recover more or less than this average, depending on their client flow and variety of services provided. CSIs new business plan proposes to increase their financial independence and to diversify sources of funding for better sustainability. Bearing in mind that USAID support will be withdrawn in 2009, and their current clientele, it is unlikely that the CSI clinics will be able to provide services for less well off people of any age. The EFPA central office is aware of the problem and intends to develop some strategies to address it. One intention is to set quality standards in its clinics in such a way that they serve a certain niche of the target population and lessen the potential competition with MOHP FP/RH clinics. This will almost certainly restrict their target populations even more. It would appear that a more fundamental and strategic approach is required, at least in some locations, and especially if less well off segments of the population are to be targeted. A further threat to institutional sustainability of the EFPA is the high turnover of EFPA staff over recent years, particularly given the relative shortage of human resource with skills to 14 The Minya CSI clinic visited has 5 staff. This is a very large number of staff given that the clinic receives an average of 50 clients each week. UNFPA and IPPF Evaluation: Egypt Country Report 43 design and manage youth-oriented SRH programmes in Egypt (see section 3.2.3). A large proportion of the administrative and clinic staff are seconded from the Ministry of Social Affairs (MOSA), and clinic doctors are largely seconded from the MOHP. Doctors are recruited with great difficulty, partly because they receive full benefits and bonuses if they continue to work for the MOHP directly. However, some doctors chose to forgo these benefits and work for FPA clinics because the limited hours allow them to work in private clinics in the evenings (the same applies to doctors working in public services). The programme needs to give specific attention to strategies to increase retention of staff. The imminent retirement of the director also poses a possible threat. One of the senior Cairo office staff also stated that many FPA activities have relied on voluntarism, but because of the increased cost of living, it is getting more difficult to find willing volunteers. This is expected to have an impact on the sustainability of project activities such as all outreach efforts. It is however, not clear how much this will affect the youth programmes - interest of young volunteers seems to have been sustained in the Youth to Youth programme, although external funding has ceased. UNFPA and IPPF Evaluation: Egypt Country Report 44 SECTION 3: INSTITUTIONAL ARRANGEMENTS 3.1. UNFPA Country Office's Institutional Arrangements 3.1.1 UNFPA Relevance Country Office Staff At the time of the evaluation, the Central UNFPA Country Office team was composed of only four core staff members: the UNFPA Resident Representative, a Deputy Representative (Egyptian), a Junior Professional Officer (JPO) and an administrative/financial staff member, supported by one assistant and a few drivers. The Deputy Representative and the JPO are responsible for project design, field visits and monitoring of project activities. External experts in different sub-programme fields are called in for assistance. At the time of the evaluation a RH consultant was present and another consultant was assigned to exploring youth perceptions of “youth friendly” services. UNFPA technical backstopping at different stages of projects is available at the Country Support Team (CST) in Amman. The overall organogram is now in the process of updating, the latest available for 2002 being attached in Annex 7. Level of Resource Allocation to Young People’s Activities As mentioned earlier, in the 7CP, the youth-oriented project “Meeting the RH needs of adolescents” will receive 75% ($6 million) of the budget for the RH sub-programme and 33% of the total UNFPA funding (see section 2.1). Monitoring and Evaluation All UNFPA-supported projects are subject to the UNFPA M&E system. Project staff prepare progress reports on a regular basis and an Annual Project Report (APR) is forwarded to the executing agency and UNFPA. UNFPA CO follows-up through field-visits, which are reported and shared with the project management staff. The Mid-Term Review (MTR), conducted by both the Government and the UNFPA reviews the assistance in relation to the country’s needs. At the close of the projects an End Project Evaluation and a Final Project Report are drafted. The first report provides input for the Country Assessment while the latter summarises recommendations. Project Review Meetings are held and provide input for the Sub-Programme Meeting, which in turn is aimed at reviewing UNFPA-supported activities under a given sub-programme. Each CP is evaluated during a programme review process prior to design of the next CP. A major weakness of the CPS to date has been that the indicators for the majority of projects have been output or process related, such as the number of training sessions held, the number of videos produced, and manuals printed. There has been limited monitoring of the effectiveness of any interventions (including IEC materials and strategies, see section 6.1.5). Neither the MOHP nor the RH project collected data on service utilisation disaggregated by age, so it is not even possible to assess to what extent young people are using the regular RH. These shortfalls result in inability to adapt the projects during the course of implementation, render it difficult to arrive at best practices for future endeavours, and obscure assessments of achievement of CP objectives. For the 7CP, UNFPA has prepared a results-based programme management plan, covering monitoring and evaluation. Most of the youth-oriented projects have logical frameworks attached to the project documents. However, again, the level of indicators are all output indicators and do not refer to changes observed due to project interventions. Both outcome UNFPA and IPPF Evaluation: Egypt Country Report 45 and output indicators are defined in the UNFPA results based and resources framework included in the UNDAF context. Young people are explicitly mentioned in the outcome indicator: “to have contributed to an increased use of quality RH services, particularly among young people” and this is further spelled out in an “increase in percentage of adolescents utilising RH services”. The four related output indicators are: § Increase the percentage of adolescents and youth knowledgeable about the risks of contracting RTIs, STIs/HIV/AIDS and means of prevention § Increase the percentage of adolescents and youth using services in selected outlets § Increase the percentage of adolescents and youth who disapprove of harmful practices to women’s health § Percentage of clients (no age specified) using and satisfied with services This will require major inputs into improving the health information and M&E systems, which should as far as possible be institutionalised in existing organisations The Multi Year Funding Framework has its own indicators, and these to a great extent coincide with Millennium Development Goal (MDG) indicators. RH indicators related to adolescents include: the adolescent (15 to 19) fertility rate and HIV prevalence in persons aged 15-24. Reproductive rights indicators include national mechanisms to monitor and reduce sexual violence, which in the case of Egypt are not yet in place. According to the UNFPA, staff reports are submitted every year. However, the framework is ”too global level focused and as such there are many gaps to report on the specific country details”. Country Programme Complementarity and Co-ordination UNFPA has always worked with a wide range of partners at the central level. These include: the Ministries of Health and Population, Information, Local Administration, Education, Ministry of Youth, Social Affairs, and Agriculture; the National Population Council; the Central Agency for Public Mobilisation and Statistics; the Cairo Demographic Centre; local Family Planning Associations as branches of EFPA; governorate and district level authorities in selected Priority Focus Areas and NGOs. Implementing agencies include government ministries, particularly the MOHP, the EFPA and various other NGOs (see section 2.1). UNFPA's strategy in improving its cooperation with the MOHP is to promote national ownership of the CP, which was a main recommendation of the thematic evaluation. Constraints in implementing the CP have been due to poor collaboration in the population field in general but also to significant weakness and lack of relevant capacities at the ministerial levels. UNFPA has made efforts to ensure that its programmes complement those of other partners. For example, under 5CP, the enormous USAID contribution to IEC led to UNFPA deciding to devote its attention to overcoming obstacles to FP identified in Upper Egypt and to cultivating opportunities to reach youth, the organised sector and community groups. In the 7CP, UNFPA increases its attention to girls’ education, early marriage and domestic violence and FGC, and will collaborate with and support concerned councils such as the National Council for Women (NCW) and the National Council for Childhood and Motherhood (NCCM). There is also much potential for complementing the inputs of other partners. One example is involving the physicians who have been trained in adolescent RH (with USAID support) in UNFPA funded projects. The main mechanism for donor co-ordination is the Donor Assistance Group. The UNFPA chairs the health and population thematic sub-group, which, inter alia, produced a matrix giving an overview of who is doing what, where, with whom and for how much. UNFPA also participates actively in a donor co-ordination committee for health, which meets on a regular basis. Participants include USAID, Ford Foundation, WHO, UNICEF and EU. UNFPA has UNFPA and IPPF Evaluation: Egypt Country Report 46 facilitated development of national plans and sectoral plans in line with the ICPD POA, through for example, supporting inter-ministerial workshops. Through these partnerships, UNFPA has the opportunity to encourage the MOHP to incorporate comprehensive RH care in the basic health care services and address youth. UNFPA staff perceive their role in co-ordinating the efforts as key for the following reasons: § UNFPA has access to all UN agencies, so that it can work in an integrated way. § UNFPA has a positive multicultural mind-set, and brings in ideas from different donors. § UNFPA has a history in Egypt and is better placed to address sensitive topics at the central and ministerial level. § UNFPA has access to funding, as many donors would like to contribute through UNFPA. There are several good examples of co-ordination and joint funding of initiatives. UNFPA contributed, with other donors, to establishing the National NGO Centre for Population and Development (NCPD), which was set up in preparation for the ICPD, and a firm partnership has resulted. The NCPDs first project in 1996, a capacity development project entitled “Support to NGOs towards the implementation of the ICPD Programme of Action”, was jointly funded by UNFPA, the EU, USAID, the Dutch Embassy, and the Ford Foundation. The research “Transitions to Adulthood: a National Survey of Egyptian Adolescents" (or ASCE) was an multi-partner initiative of the Population Council, Social Research Centre, High Institute of Public Health, and Assiut University, jointly supported by UNFPA, CIDA, the Government of the Netherlands, the International Development Research Centre of Canada, Rockefeller Foundation and UNICEF. Despite these examples of collaboration, it is generally felt that the lack of co-ordination among actors in RH, PDS, IEC and advocacy, leads to poor geographical and thematic distribution or utilisation of resources, and even duplication of efforts. A case study of the Population and Development Strategies Project in 2002 found that despite the mechanism, only a modest level of co-ordination was evident amongst the donor programmes in population, mostly in the form of information sharing15. To overcome the lack of co- ordination, UNFPA has initiated a project in the 7CP “Unit for Monitoring Population Activities”, based in the MOHP and aimed at making an inventory of all RH- and population- related activities. There is also evidence of missed opportunities for co-ordination of effort between UNFPA- funded projects. For example, the "Youth Leadership Development" and EFPAs similar "Youth to Youth" project, both funded by UNFPA, had similar objectives and target groups. Both trained youth volunteers/facilitators in population, FP and RH issues and provided them with communication skills to transfer RH and FP messages to their peer audience. However there is little evidence of any joint working or lesson learning. The training and IEC materials were developed separately, with no sharing or transfer between the two projects. The involvement of youth in the design of the first project was not mirrored in the EFPA project, which was developed by adults. Such missed opportunities to join forces, and share expertise, resources, monitoring tools and findings, compromise efficiency and the potential for synergy. United Nations Development Assistance Framework (UNDAF) The UNDAF (2002), lays the foundation for the co-operation of UN Programmes, Funds and Agencies in a given country. It is preceded by a Common Country Assessment (CCA), the 15 Peter Morgan and Nader Fergany, March 6, 2002 UNFPA and IPPF Evaluation: Egypt Country Report 47 first of which took place in Egypt in 2001, led by UNFPA. United Nations Agencies and Programmes were organised in thematic groups, which worked closely with Government of Egypt counterparts on specific subjects. This led to the preparation of the UNDAF 2002- 2006, into which UNFPA’s 7CP is integrated. The overarching goal for UN system development cooperation is to promote a more people centred development strategy based on rational and efficient use of Egypt’s institutional capabilities, natural resources and human assets. Women, children and youth are identified as critical areas that require particular attention and deserve to be addressed with renewed commitment and effectiveness. One specific objective is to reduce gender disparities and another is to promote a coherent and systemic action from all stakeholders to address the rights of Children and Youth (youth are defined as up to 18 years old). However the ICPD is not alluded to in the document, and although RH for youth is mentioned, reproductive rights are not specifically mentioned. Relation to Civil Society UNFPA has a long history of working with NGOs, but collaboration with youth-focused NGOs only started shortly after the ICPD. NGOs gradually became sub-contractors or executing/implementing partners in addition to the traditional governmental ones. Youth- focused programmes designed and implemented under UNFPA’s support, involved NGOs such as CEDPA and the Youth Association for Population and Development (YAPD), the Egyptian Federation for Scouts and Girls Guides, the EFPA and the EFPA-affiliated Institute for Training and Research in Family Planning (IRTFP). UNFPA’s collaboration with EFPA is discussed in section 3.2.1. Since the introduction of a new funding modality, UNFPA allocates funding directly to selected NGOs instead of going through MOHP who previously subcontracted the NGOs. UNFPA perceive this modality as an opportunity to support more innovative interventions. UNFPA's direct and indirect relationship with civil society also includes the volunteers, facilitators and youth outreach workers who were involved in UNFPA funded project activities. In the advocacy sub programme, collaboration was established with the media world at central and local levels. 3.1.2 UNFPA Integration of Rights Generally speaking, UNFPA encourages recruitment of female staff at all levels. The current Country Representative is male, and the Deputy Representative is female. In addition, the UNFPA employs one Young Professional (who is also a female), and seeks to involve youth in the agency’s work by offering youth internships to international students. Staff also mentioned the Model United Nations (a simulation of the General Assembly for students) as one way in which youth contribute to the organisation’s agenda. Moving away from internal work norms and towards their programmatic activities, UNFPA staff were of the opinion that, given the Egyptian socio-cultural context, rights issues needed to be gradually introduced. The CPs under review illustrate this issue and the 7CP is more explicit in its addressing of RH rights (see section 2). However staff feel that NGOs are in a better position to address rights than UNFPA. 3.1.3 Capacity of staff The UNFPA core staff are few, and those met at the time of the evaluation were relatively new to the organisation. They admitted to having rather limited experience with youth- oriented projects in both the service and IEC/ advocacy field. Like other organisations in Egypt, UNFPA as an organisation has had limited experience in designing programmes for UNFPA and IPPF Evaluation: Egypt Country Report 48 different sub-segments of youth. Hence the competence or the capability to deliver technically sound youth programmes is restricted to lessons learned from other, more general, projects. CO staff have, however, gained some experiences by learning-by-doing, for example in campaigns highlighting youth RH and rights issues. Although programme staff interviewed were relatively new to the organisation, they demonstrated adequate understanding of the dimensions of young Egyptians’ RH circumstances, and were very aware of the socio-cultural context of SRHR for young people in Egypt. They are knowledgeable of available data sources, which support their arguments. They understand to a certain extent the critical influence of gatekeepers such as decision makers, religious leaders, parents and teachers, showed capacity to adapt to new approaches to youth, and expressed willingness to increase their attention to the issue of RH rights in forthcoming projects. However, despite the awareness and understanding of the role of gatekeepers, there has so far been insufficient targeting of these groups with messages that are tailored to their different concerns. Men, as gatekeepers of traditions and traditional gender roles, have also been to a great extent neglected, and their influential role on women’s and youth’s SRH and rights has so far has been underestimated by the UNFPA. In the Egyptian context this is crucial to the success of youth programmes - there is good appreciation of the fact that the establishment of youth friendly services may not automatically mean that youth have access to them, as youth are still very much protected by parents, (male) partners and others. Social control is still rather strong in the Egyptian culture. There is also an appreciation that RH and rights messages need to be culturally appropriate and well tailored to the different audiences and gatekeepers, ranging from very traditional in rural areas to more modern urban population segments. UNFPA is already partially remedying limited staff capacities by learning exercises, such as designing youth projects based on thorough needs assessments. However, given the scope of the ICPD-POA, the particular challenges of the Egyptian context, and the need to better co-ordinate the work of many partners, more staff and relevant additional technical support is required to ensure the achievement of the 7CPs’ ambitious objectives. The office has relied heavily on external expertise, and will continue to do so, particularly for developing youth- friendly responses in the project “Meeting the RH Needs of Adolescents”. However, generally within Egypt, there is limited capacity and experience to dealing with youth programmes, even in the NGO sector, and this is a further limiting factor. Furthermore, although external assistance facilitates matters in the short term, by relying on it heavily UNFPA runs the risk of not developing specialised technical skills within the organisation. It will be unable to provide technical expertise and its role will therefore be limited to a managerial one. Young People’s Participation Although the CO team acknowledges the importance of participatory approaches in young people's RH programmes, no institutional mechanisms exist for the inclusion of young people in policy development, or programme design and management (see 2.1.1). Apart from one project, there has been minimal involvement of youth in project design and management. UNFPA’s formal partners in the 7CP do not yet include any youth organisations. The CP respects equal employment opportunities for women, and policies and practices within the CO provide scope for youth input in the form of the position of Junior Professional Officer. UNFPA staff are aware that institutional arrangements need to be developed at policy level within the organisation. UNFPA intends to network with youth organisations in the coming period, but needs a more systematic strategy on how to involve youth, selection criteria, and how to train youth in the planning, design, implementation, monitoring and evaluation of projects. UNFPA and IPPF Evaluation: Egypt Country Report 49 Integration of Assessment and Evaluation Findings into project design In general the focus and strategies of each CP has taken into account the outcomes of the preceding PRSD and thematic evaluations. For example, evaluation of the 5 CP (in the PRSD Report for the 6CP) mention the 5CP’s overemphasis on women and FP, too little effort directed towards men, and a neglect of the wider RH and rights issues such as gender and harmful practices (e.g. FGC). Efforts were made to redress the balance in the 6 CP. A recommendation under the RH sectoral strategy proposal (1997) also stressed the urgent need for the development of a comprehensive RH initiative for adolescents. UNFPA then supported the development of the National Adolescent Strategy in 2001. This has fed into the new National Population and RH strategy, and is currently (2003) being operationalised and a holistic project design is being developed by UNFPA in cooperation with the EFPA. The outcomes of two thematic evaluation reports are being applied in the design of forthcoming interventions. The success of an assistance cycle depends not only on competent staff in the CO and CST, on relevant focus or strategy and M&E. Technically sound project design is also essential, informed by a good M&E system. In practice, project designs have not always been in line with the CPs focus and strategies, or technically sound, and significant delays have occurred in integration of evaluation recommendations (e.g. development of a comprehensive RH initiative for adolescents, mobilisation of men in responding to adolescent RHR needs). Recognising this, UNFPA has moved towards more evidence-based planning, promoting baseline assessment studies and in depth situation analysis as a routine exercise prior to project development. The Advocacy Component project used outcomes of an anthropological study to translate RH and rights into local terminology. The Youth Leadership Development Project prioritised youth topics with youth audience and the manual is strongly based on the preferences of the participating youth (see section 6). A study on adolescent perceptions of “youth friendliness” is being conducted to guide the forthcoming project, Meeting the RH needs of Adolescents. Despite these initiatives, the evaluations of some component suggest that more needs to be done on evidence-based development of programmes. UNFPA is also attempting to identify best practices and move closer towards their institutionalisation to improve sustainability. The RH integration in PHC project, which was institutionalised and implemented by the MOHP, was perceived as being a good model of sustainability, to be replicated. Partly as a result, the majority of the 7CP projects are going to be implemented by the MOHP. On the other hand, another project (Youth Leadership Development Programme, CP5) which was considered to have had very positive outcomes will not be further supported by UNFPA. According to the Youth NGO responsible for the project, it received a reward for its successful intervention. The 6CP praises the same project as an initiative that “generated remarkable enthusiasm among youth, demonstrating the strong potential for its expansion”. Neither the representatives of the NGO nor those of the UNFPA could explain why UNFPA is not continuing support for the project, though the 7CP document suggested this might have been related to the issue of sustainability. As the 7CP projects were still in their development stage during the mission, it remains to be seen whether and how the positive experience of these two projects is utilised in the design of the 7CP projects. UNFPA intends to integrate the good practices of active participation of youth and an in-depth assessment of their needs into the design of forthcoming youth projects. However, the mission had the impression that youth-friendly services were perceived as a completely new intervention. It should be noted that best elements from projects that are not specific to youth can be transferred to youth projects, in particular the client-friendly, cost-effective and sustainable approach adopted in the integration of RH in PHC initiative. UNFPA and IPPF Evaluation: Egypt Country Report 50 Country Support Team Team members of the Country Support Team (CST) in Amman participate in evaluations, in Programme Review and Strategy Development exercises and provide technical input in selected projects. The CST appeared to have played a strong role in the 6CP PDS project and supplied useful technical advice such as information management strategies. However, UNFPA staff made no mention of CST assistance in the forthcoming adolescents and youth project. HQ recently assigned a new role to the CSTs in compiling and sharing best practices in the field of RH and rights and gender, and they are encouraging the CO to contribute to this. 3.2. The FPAs Institutional Capacity and Arrangements 3.2.1 FPA Relevance Organisational Structure The EFPA has a central office located in Cairo and 25 member FPAs in all but one of the governorates. The total number of staff at the EFPA central office is 21. Until recently no specific staff member was assigned to work on youth-related issues. However, the EFPA has recently restructured as a result of the review conducted by IPPF, and the most recent organogram is presented in Annex 7. A Youth and Gender assistant will be appointed in the programme department. The main office has an executive board of 15, and five technical committees: 1. Medical committee. 2. Women and Youth committee. 3. Planning and resource development committee. 4. Executive committee for the clinical services improvement (CSI) project. 5. Committee for the management of Alexandria ITRFP. The Woman and Youth committee will be responsible for setting strategies for women and youth development from the social and health perspectives: 1. Suggesting strategies and policies to ensure representation of women and youth in committees and institutions affiliated to EFPA 2. Study plans and projects submitted in the field of youth and women and suggest strategies for monitoring and evaluation of their activities. 3. Support collaboration among agencies working in the field of women and youth at the national, regional and international levels. 4. Suggest policies in the fields of health, reproductive and sexual health for women and youth. However these various committees have only recently been set up, and their roles have not yet been identified. EFPA defines itself as a federation of autonomous organisations with a central office. There are 25 member FPAs who are all affiliated to the central office and all have identical board and staff structures. Branch FPAs have a certain degree of autonomy. They can, for example, independently source finances and develop projects with donor agencies. There is therefore no reason why they should not seek funding for youth projects themselves, but in practice this has not happened. The central EFPA welcomes branch offices’ pursuit of funding, but it is not activated by any internal strategy or policy enabling or supporting FPAs to seek external funding sources. Those at the implementation level have had not specific training on how to sustain their activities. UNFPA and IPPF Evaluation: Egypt Country Report 51 The ITRFP (Institute for Training and Research in Family Planning) is considered as a separate partner, although it is still partially funded and supervised by the central EFPA office through a Management Committee. It also solicits funds independently of the EFPA and manages its own projects. 31.5% of its total activities are funded by international organisations such as UNICEF and UNFPA (e.g. the Youth Leadership Development project). Its involvement in the latter has built up some expertise in training young people, and the manual it produced has potential for use on s widespread scale. ITRFP has a high level of credibility in Egypt. It is however facing increasing competition from other training institutes such as the Regional Centre for Training in Family Planning and Reproductive Health and the training centre recently established by the MOHP. CSI is a small, well managed NGO administratively affiliated to EFPA, but funded directly from government and donor agencies (USAID). It has its own management body with a small number of core senior staff and some support staff. The main office (located in Cairo) is connected to all branches (88 branches) electronically. The CSI clinics have not had a focus on young people to date, but the EFPA considers that they have good potential for the provision of RH services for young people. It would appear however that these would only be accessible to better off youth. Resource Allocation to Young People’s RH There is no data on the total EFPA resources devoted to youth programmes over the period under review. The proportion of the budget from IPPF allocated to youth is shown in section 2.2.1. In the years 1996, 1997, 1998 the percentages allocated to youth projects were respectively 5.7%, 7.3%, 7.4 %, falling to 3.2 % in 1999, and nothing in the years 2000 till 2002. However, when project funds from this source were frozen whilst IPPF carried out its evaluation, EFPA accessed other funds to implement youth related activities in some local offices (e.g. FGC project in Assuit Governorate, funded by UNICEF). In 2003, 17% of the IPPF/EFPA budget is allocated for advocacy and youth activities. In addition, EFPA will get $ 366,412 from the UNFPA to implement the Meeting Adolescents’ RH Needs Project over a five-year period. Monitoring and Evaluation All clinics record the number of women broken down by new clients, repeat clients, and those who are late, according to the type of contraception provided. The form also states the number of women who have received other RH services according to a standardise list. However, none records age and there is therefore no information on the proportion of clients who are under 25. This will need to change if the services are to become more youth oriented. Performance targets for each governorate are set for the EFPA by the National Population Council. EFPA clinics hold monthly staff meetings to review problems and progress. The clinic maintains boxes for complaints and suggestions, and tries to respond to clients needs. Each clinic under the supervision of a given branch office compiles information on services delivered and performance on targets on a standardised form, also shared with the EFPA office. Monthly financial reports are submitted by branch FPAs to the central EFPA office in Cairo. Monitoring of projects is done to a certain extent. Some of the projects have baseline surveys and many have had mid-term and final evaluations, including one youth project in the “Development and Support of RH Services” in EFPA branches in Alexandria, North Sinai and Assuit Governorates (1998-2000). Projects such as “Youth to Youth” produced monthly narrative reports on seminars held, as well as monthly field visits by senior staff from the Cairo office, and standardised reports. However most information is limited to outputs (such UNFPA and IPPF Evaluation: Egypt Country Report 52 as number of youth volunteers trained, topics of seminars held, etc) and there has been little monitoring of outcomes or impact. EFPA staff have indicated their plans to develop a strong management information system among their branch offices to follow the strategic focus on young people and their reproductive rights. However, their plan was not fully developed at the time of the evaluation. It was also not clear from either the organogram or staff interviews whether there are specifically assigned staff for monitoring and evaluation functions. EFPA partnerships with key partners including UNFPA EFPA has formed partnerships on a project by project basis. For example, in the Youth Leadership Development project, partnerships were forged between UNFPA (which provided funding), CEDPA, the Egyptian Federation for Scouts and Girl Guides, and the Youth Association for Population and Development (both of which provided facilitators and implemented activities). Selection of the implementing partner (ITRFP) was appropriate, as the institute is a national training centre specialised in family planning and population issues. However, as explained above, EFPA has only recently started to articulate its approach to young people’s RH and rights. Youth-oriented activities in the past have been implemented as isolated projects, and not within any policy, strategic or organisational framework. Although EFPA has collaborated with a wide range of partners, it does not appear to have built up any strategic or institutionalised organisational partnerships for youth activities. The new Strategic Plan, with its focus on young people, and EFPAs prospective involvement in the UNFPA 7CP offers an opportunity to identify what its strategic role will be in relation to service provision, advocacy and IEC, and ensure that both its approach and services are complementary to and coherent with the national approach. The EFPA and UNFPA have collaborated on youth projects since the mid 1990s, starting with the “Youth Leadership Development Project” funded by UNFPA. The ITRFP developed training curricula, and trained advocates and youth leaders from different EFPA central and local offices. However although EFPA was also involved in another similar UNFPA-funded youth project around the same time, there appears to have been little joint working or sharing of best practice between the two projects. UNFPA and EFPA are now working together on the development of protocols and guidelines to support the implementation of a package of youth friendly services; and training of service providers to improve quality of service provision to young people. 3.2.2 FPA Integration of Rights EFPA has not yet established any mechanisms to involve young people directly in the management of the organisation or the programmes. However, they expressed the intention to hire two young staff not older than 35, one male and one female, to manage a planned Youth Resource and Information Centre at the Cairo office, and are currently considering recruiting a young person to the organisation's board. There was no information on the age of FPA employees, but the impression on field visits was that all staff were middle aged, with the exception of two relatively young staff members in the Daqahlia office, both of whom had been former participants in the Youth to Youth project. As elsewhere in the world, men tend to occupy senior management positions in EFPA, and women tend to predominate in service delivery and project implementation. The present Board has 15 members, four of whom are women. Although the current director of EFPA is female, most of the other high executive positions are occupied by men. Three out of the four senior staff interviewed in the EFPA central office were men, who made no mention of hiring a female in an executive position in the near future. Of the four executive directors of UNFPA and IPPF Evaluation: Egypt Country Report 53 branch FPAs the evaluation team met, one was female. On the other hand all staff except one in the visited clinics were women. At least two FPAs visited by the team had several local board members that were female. The remaining administrative staff of almost all FPAs had nearly equal male and female representation (except in the Daqahlia office, where there were hardly any female staff). Professional staff observed at the ITRFP were predominantly female, and on the average, older than 25. At central level however, staff were predominantly male and above 30 years of age. 3.2.3 FPA Capacity The EFPA has not had any specific capacity to address the SRHR of young people. Indeed its capacity to deliver services generally has been put to the test over recent years by a high turnover of second line management and programme staff, including several changes in the Executive Director and the loss of the Advocacy and IEC assistant. An indication of the high calibre of staff lost is that they have all moved on to international agencies’ programmes (including UNFPA). Staff attrition is largely due to better employment packages offered elsewhere and a lack of potential for career development within the EFPA. There are some indications that the capacity of EFPA and its affiliates to meet performance targets is now being compromised. The level of target achievement ranges from 53% to 86% of the set targets. Some of this failure is attributable to financial constraints, partly as result of decreased funding from IPPF, and in some cases, reduced income due to increasing competition from the MOHP (see section 2.2). The new organogram addresses some of the organisational capacity constraints, including the appointment of a Youth and Gender assistant, and reflects the broader goals of the ICPD (see Annex 7). However, most of the technical jobs in the new structure are still vacant. The current limited number of staff at the central level will face a big challenge to achieve the current ambitious strategic goals and objectives unless new staff with the requisite skills and expertise can be recruited. The concepts of young people’s reproductive health and rights are understood and articulated to a certain extent by senior management, as demonstrated by the new strategic plan. The new mission statement says that the EFPA will provide services “in response to the needs of underserved groups”. It aims to “improve access and respond to the needs of those who face obstacles related to socio-economic, geographical, cultural and other gender issues”. Programme staff have some understanding of the complexity and diversity of needs within the country context, based on baseline studies that reflect the diversity of needs across the national programme. Interviews with central staff, and those at implementation level, illustrated their willingness to work with youth. This is not yet operationalised as it was still in the planning stage at the time of the evaluation. Despite good intentions however, neither the central office nor the local branches are adequately prepared to address issues unique to youth, or to implement approaches tailored to youth. EFPA central office has carried out several in-country training activities with IPPF financial support, and USAID and the EC have also supported training. It is not clear that these trainings were based on any assessment of needs in the area of RH for youth, although the USAID training was based on a self-administrated needs assessment questionnaire. In addition, IPPF included EFPA selected staff in their regional and international training activities. Such training has the potential to address the weaknesses in capacity to design and manage youth-oriented SRHR programmes. UNFPA and IPPF Evaluation: Egypt Country Report 54 SECTION 4: ENABLING POLICY DEVELOPMENT AND REFORM 4.1. UNFPA Country Programme 4.1.1 Relevance Focus on policies and legislation relating to young people’s RH and rights Since ICPD, several of the CP components have focused on policy and legislation issues that are relevant to the young people of Egypt, in particular the IEC and advocacy component and to a certain extent the PDS (see section 2.1). The national advocacy programmes have focused on the provision of RH education to young people, FGC, education of girls, forced marriage, early marriage and child bearing, gender disparities and promoting the status of women, as well as lobbying for a more holistic approach to RH. The FGC campaign has covered medical, legal, religious and cultural aspects (see section 6.1). Localised projects, targeted mostly at youth, have attempted to raise awareness about the same issues. UNFPA has also aimed to some extent to promote the concept that young people have a valuable contribution to make in planning policy and programmes. A particular focus of the work of UNFPA has been promoting greater understanding among adults, including the medical profession, that young people have particular health and reproductive health needs. The development of the first National Adolescent Strategy by the MOHP was a major step forward. This has been followed up by continued support for the development of the new National Population and Reproductive Health Strategy that includes, inter alia, a strategy for improving the health and development of adolescents and youth. However, as pointed out in section 1.2, this has certain weaknesses, and does not address, for example, the issue of access to RH services for unmarried youth. Relevant policy and legislation issues that have not been aggressively addressed or pursued include access to RH for unmarried young people, both male and female, the issue of sexual and reproductive rights, and the whole area of sexual health. Other issues that require more focus are traditional deflowering, domestic violence, and marriage to close family relations. Abortion and HIV/AIDS are not perceived as major problems for young people in Egypt, but should not be ignored in the policy and legislation debate given the rise in sexual activity found in university students and lack of knowledge of safe sex (see section 1.2) Mainstreaming of gender in health and in the National Development Plan will also receive attention in the new CP, in the Mainstreaming Gender in Development: Planning, Institutionalisation, Monitoring and Evaluation in the PDS programme. 4.1.2 Efficiency and effectiveness There is evidence from evaluations and from comments of stakeholders, that UNFPA has been effective in stimulating and facilitating public debate within important key groups, such as religious leaders, on sensitive issues such as FGC, and forced and early marriage. It is difficult to say exactly how much of the programme has been allocated to policy reforms as policies have been addressed within different components and the structure of the budget has changed in each CP (see section 2.1). The 5th and 6th CPs allocated 10% and 22%, respectively, of the budget to advocacy and/or IEC, and 23% and 24%, respectively, to PDS. Given that UNFPA is credited with having effectively challenged deeply embedded cultural and religious traditions and beliefs in an acceptable and non-confrontational manner, this effort appears to have been an efficient use of resources. UNFPA and IPPF Evaluation: Egypt Country Report 55 The 7th CP has recently allocated 39% to PDS, which includes both advocacy and IEC – suggesting only a slight decline in the proportion of funding. Due to the high turnover of central office staff, there is limited institutional memory within the UNFPA, and it is difficult to assess how human resources were allocated to policy issues in the past. However, the current Country Representative has devoted a large percentage of time to addressing policy. According to the Programme Review of the 6 CP, UNFPA assistance to donor co-ordination in the population sector, and the Fund’s advocacy, was effective in raising support from other organisations to youth RH issues, in strengthening the capacities of the NGOs and in launching FGC campaigns. UNFPA’s advocacy campaigns have slowly contributed to a greater acceptance, and less criticism, of the concept of SRH of young people inherent in the ICPD POA. The national advocacy programme of the 6CP appears to have been successful as it promoted dialogue between and among key groups e.g. religious leaders, politicians and youth. It further enhanced media capacities to discuss specific topics, although it did not build up the capacity to develop and launch evidence- based campaigns. Through its support for the adolescent health strategy, and then the NPRHS, UNFPA has succeeded in introducing and gaining acceptance of the concept of adolescent health, and to a limited extent, adolescent reproductive health. It has now been institutionalised, at least in the official strategy documents. In the Egyptian context this is a major step forward. However, the NPRHS is still relatively conservative, and does not address the issue of access to RH services for unmarried youth, or the issue of rights (see section 1.2). It also lacks a comprehensive strategic assessment of how existing resources used by young people could be harnessed for counselling in RH (e.g. pharmacists and the private sector). The limited progress in the area of access to RH services and the promotion of rights needs to be assessed not only in the general socio-cultural context (see section 2.1), but also in the context of the working environment. In the early years of the 5CP, the MOHP was exclusively oriented towards FP and lobbying for RH and rights in general and for adolescents and youth in particular was extremely difficult (see section 2.1). Moreover, this was an unfamiliar target group for the UNFPA. UNFPA’s intention to contribute to the elaboration of an integrated policy linked to inter-sectoral interventions (e.g. in poverty alleviation) had a restricted audience within the MOHP. In the 6CP UNFPA had to cooperate with a recently established line ministry (MOHP) that had neither experience in co-ordination nor in tackling social and economic variables connected with population issues. It is generally acknowledged that the impact of the CP was significantly impeded by the MOHP bureaucracy, which was more interested in solving short-term crises than in investing in the PDS with its longer-term benefits. Moreover, all MOHP staff were medical doctors and clinicians who had little interest in non-medical fields and were not inclined to look at broader RH issues recommended by the ICPD. Progress in a dialogue on SRH for young people remains difficult, making UNFPA’s achievements all the more important. 4.2. EFPA EFPA has not been directly involved in major RH policy reforms. However it has contributed to the debate and to raising awareness of relevant issues such as FGC, early marriage, and women’s rights. In particular, it specifically refers to rights in the context of women, religion and reproductive health (see section 2.2). In recent years, the EFPA has initiated national action in the areas of women’s empowerment, and youth. EFPA recommendations on women, regarding the expansion of women’s clubs, the role of women in policy, and awareness raising among girls before marriage regarding reproductive health service needs (like premarital examination and delaying age of marriage), have been recognised by the government and considered appropriate by the Egyptian Parliament. UNFPA and IPPF Evaluation: Egypt Country Report 56 EFPA has a good level of understanding of the policy environment in Egypt. Over time, they have created close links with many national and international institutions/organisations working in reproductive health and rights. It is clear that they have the potential to be more fully engaged in, and influence, the policy debate, particularly given their experience of implementing policy in the field. However, this would require a more pro-active and objective role, and the efficiency of such an investment should be weighed against their current comparative strengths in service provision. UNFPA and IPPF Evaluation: Egypt Country Report 57 SECTION 5: STRENGTHENING REPRODUCTIVE HEALTH SERVICES 5.1 UNFPA Country Programme 5.1.1 Relevance Support to RH services for young people In the 6CP, UNFPA intended to support the MOHP to provide expanded, quality RH and FP services integrated into primary health care (PHC). Two projects, the Pilot Implementation and Evaluation of the RH Framework, and its extension, The Expanded Use of the RH Framework, were implemented as research/demonstration projects over 7 years. Target groups were the general population, but with special attention to women and youth. These projects were designed on the basis of the Giza Morbidity Study, and a nine-month baseline study in which adolescents were included. However, as explained in section 2.2.1, although the services were women oriented, there was never any explicit focus on designing or modifying services for youth. It is not clear why the project lost sight of adolescents’ needs in its implementation phase. The revised and expanded RH service package comprises family planning, antenatal and postpartum care and gynaecology. Because the service model was developed by a multi- disciplinary research group, it addresses more than the medical aspects of RH, including sociological, cultural, economic and administrative perspectives. The services are used by married women, including young married women, but this appears to be the only group of young people included. The RHR needs of unmarried young people, either male or female, were not addressed in the development research, nor even explored. Prior to the 7CP, therefore, the intention to promote and support RH services for youth had been stated, but not materialised. In the 7CP, focused interventions for adolescents and youth will be introduced. The Meeting RH Needs of Adolescents project will receive 75% of the total UNFPA budget allocated to the whole RH sub-programme, and 33% of the total UNFPA funding. Many of the lessons learnt from the “client-friendly” RH services may be applicable to increasing adolescents’ access to “youth-friendly” services. Examples are the balance between dealing with technical and social RH aspects, and the emphasis placed on ensuring skilled professionals accept, and are able to respect, clients' rights. Nonetheless, expanding access to unmarried young people will require specific expertise in youth–oriented programmes to translate these lessons into appropriate strategies. Given the importance of gatekeepers to the lives of younger cohorts, additional research will be needed to better understand the attitudes of parents and community members to young people's utilisation of services. A deeper understanding of provider attitudes towards youth would also be useful. Distinguishing between the needs of sub-groups within the population of young people based on their circumstances, access to facilities and so forth will be critical to the provision of relevant and effective RH services to each group of potential clients under this project. At the time of the mission, a consultant was assisting the UNFPA in designing this project. FGDs and needs assessments are assessing youth perceptions of “youth-friendly” services and appropriate concrete strategies to translate the outcomes into service will be recommended. Diversity in the needs of the female and

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