Documentation of the Use of SPARHCS: Egypt

Publication date: 2006

The Strategic Pathway to Reproductive Health Commodity Security (SPARHCS), developed by the DELIVER, POLICY, and Commercial Market Strategies projects (in collaboration with the United States Agency for International Development (USAID), the United Nations Population Fund (UNFPA), and other donors and technical agencies), serves as an assessment, planning, and implementation tool to help countries address contraceptive security (CS) issues and to determine areas for strengthening and intervention. SPARHCS examines six key areas that factor into a country’s CS situation: client utilization and demand, context, commitment, capital, capacity, and coordination. Moreover, it is a universal assessment tool that can be tailored to specific timelines, country contexts, or program objectives. The following brief outlines the experience of using the SPARHCS tool in assessing contraceptive security in Egypt. Overall, SPARHCS served to identify key weaknesses and focus attention on developing and implementing solutions. Documentation of the Use of SPARHCS: Egypt Introduction Contraceptive security (CS) is achieved when individuals have the ability to choose, obtain, and use contraceptives and condoms whenever they need them. The Strategic Pathway to Reproductive Health Commodity Security (SPARHCS) framework provides countries with a tool to assess contraceptive security and to design plans for advancing it in both the short and long term. The government of Egypt (GOE) initiated CS activities in 2003 to strategically prepare for the phaseout of donated contraceptive commodities by 2006. The SPARHCS framework and diagnostic guide was used to compile and analyze existing data on family planning and reproductive health, determine what additional information was required for a complete CS situational analysis, and prepare a strategic plan for implementing CS activities. A team from POLICY and Egypt’s Ministry of Health and Population (MOHP) conducted a situation analysis using SPARHCS in 2004. This brief describes the SPARHCS assessment and its application in Egypt, including the CS context when the team conducted the assessment; and the findings, recommendations, lessons learned, activities, and progress made since the SPARHCS application. CS Context in Egypt1 POLICY and the MOHP reviewed the demographic indicators, the history of donor financing of contraceptives, the family planning (FP) market, and the economic and political environment in Egypt to understand the context related to achieving contraceptive security (MOHP and POLICY, 2004). Demographic indicators.2 Over the last eight years, FP use among married women of reproductive age (MWRA), ages 15-49, in Egypt has increased; the contraceptive prevalence rate (CPR) for MWRA increased from 42 percent in 1995 to 53 percent in 2003. However, disparities in CPR still exist between rural and urban areas as well as in certain geographic areas; the CPR among MWRA in Upper Egypt’s rural areas was 41 percent compared with 63 percent among MWRA in the urban governates. In 2003, unmet need for family planning was about 10 percent (El-Zanaty et al., 1996; El-Zanaty and Way, 2004). History of donor financing of contraceptives. Until 2004, USAID was the principal supplier of injectables and intrauterine devices (IUDs) to the MOHP. Since 2004, the MOHP has been working under a donor phaseout plan to gradually assume the financial responsibility for procuring these methods by 2006. FP providers and methods. The public sector is the most popular source for family planning, providing 55 percent of users with contraceptive methods (see Figure 1). The commercial sector has 39 percent of the FP market, composed of private health providers (23%) and pharmacies (16%). Finally, NGOs and other sources are responsible for the remaining 6 percent of FP provision (El-Zanaty and Way, 2004). The majority of women using family planning select modern methods. In 2003, of MWRA using family planning, 60 percent reported using IUDs, 15 percent used oral contraceptives (OCs), 13 percent used 1 This section reviews the CS context at the time of the SPARHCS application. All progress since 2004 is reported in the section titled, Activities and Progress since the SPARHCS Application. 2 Egypt’s population is approximately 74 million, making it the most populous country in the Arab world. Forty-three percent of the population resides in urban areas. Women of reproductive age represent 26 percent (or 19.5 million) of the total population (PRB, 2005). 1 injectables, 6 percent used traditional methods, and 2 percent each used sterilization, condoms, and implants (see Figure 2). High acceptance of the IUD is a positive trend for the MOHP and its efforts to achieve contraceptive security, since per user, the IUD is relatively inexpensive compared with other modern methods (El-Zanaty and Way, 2004). Figure 1: Source Mix Among Users of Modern Methods in Egypt (2003) Public 55%Private provider 23% NGO 5% Pharmacy 16% Other 1% Figure 2: Method Mix Among Users of Family Planning in Egypt (2003) OCs 15% Implant 2% Injectables 13% Traditional 6% IUDs 60% Condom 2%Steril 2% Economic and political environment. The government of Egypt has a long history of support for population activities, dating back to its establishment of a National Commission for Population Matters in 1953; a National Population Policy in 1973; and a National Strategy Framework for Population, Human Resources Development, and Family Planning Program in 1980 (Zohry, 1997). In 1994, Egypt hosted the groundbreaking International Conference for Population and Development in Cairo. Now, the government has clearly articulated its commitment to sustaining access to contraceptives for all those who want them, but its commitment could be leveraged to increase awareness and support for CS activities. Specifically, high-level political support for family planning needs to be transmitted to lower levels of government, and the role of religious leaders in advocating for family planning should be strengthened in an effort to secure widespread political and popular support for family planning. Despite Egypt’s growing and strengthening economy resulting from foreign investment, approximately 44 percent of the population lives below US$2 per day (PRB, 2005). Continued economic growth in Egypt will be constrained by the limited amount of arable land coupled with the large and rapidly growing population. The government’s resources are also limited, and those resources allocated to family planning must be used efficiently and effectively. The SPARHCS Assessment in Egypt Egypt began FP sustainability efforts in May 2001 to address the phaseout of contraceptive commodity donations by 2006, but little was accomplished, in part because of limited multisectoral involvement. In December 2003, Egypt revitalized its efforts—at this point employing the concept of contraceptive security—with the goal of achieving multisectoral buy-in and to address the now imminent donor phaseout of contraceptive commodities by 2006. POLICY launched these CS efforts by conducting key informant interviews and meetings with stakeholders to raise the issue of contraceptive security, solidify stakeholder commitment to the issue, and determine Egypt’s main CS challenges. More efforts followed in June 2004 when POLICY conducted a series of meetings with a select group of stakeholders from various divisions of the MOHP to diagnose the status of the country’s FP services and contraceptives and 2 identify information sources and gaps in information needed to evaluate these issues. During these meetings, POLICY presented the SPARHCS framework. The objective of applying the SPARHCS framework as the basis for a situation analysis and planning was to support Egypt in further advancing its CS agenda, specifically in the development of group consensus around contraceptive security and a funded action plan for ensuring an adequate supply and choice of high-quality contraceptives that will meet client needs. Key players. POLICY provided technical assistance to the assessment by presenting the SPARHCS framework, guiding the assessment and collection of information, and facilitating the dissemination of the SPARHCS briefing booklet. DELIVER conducted an analysis of procurement and logistics and provided critical technical assistance regarding next steps and strategies for procurement and logistics. In addition, the CS Working Group in Egypt (CSWG)3 helped identify data sources and guided the assessment. A local CS consultant helped compile data and information from the assessment into a briefing booklet. Information gathering. SPARHCS provided a framework to assemble the key findings generated over the last five years by multiple organizations and to identify gaps in information. To identify Egypt’s main CS issues, the assessment included conducting key informant interviews with stakeholders from the MOHP/Population Sector and Logistics Unit; donor organizations such as USAID, UNFPA, the World Bank, the World Health Organization, and the European Union; local and international NGOs; and pharmaceutical companies. A review of key documents included a market segmentation study and studies on contraceptive commodity costing, client provider interaction, service provision, and procurement and logistics (Abdel-Aziz Sayed et al., 2005; NPC, 2003; Contraceptive Cost Study Team, 2003; Frontiers in Reproductive Health, 2001; MOHP et al., 2002; Ainsworth and Dickens, 2004). POLICY and the MOHP jointly held an awareness-raising workshop titled “Contraceptive Security in Egypt: Basic Issues,” from October 11–13, 2004, in Ein Sokhna, Egypt. Fifty-six multisectoral stakeholders attended, representing the MOHP, National Population Council (NPC), Ministry of Finance, Ministry of Planning, Ministry of International Cooperation, NGOs, public and private sector pharmaceutical companies, donor agencies, DELIVER, CATALYST, the health and population committees in the Shura and People’s Assembly, physician and pharmacy syndicates, research institutes, and the Population Council. Objectives for the workshop included raising awareness about and gaining support for contraceptive security by assessing the current country situation and projecting future needs for FP services and contraceptive commodities, defining policy issues associated with SPARHCS, and building consensus among stakeholders on priority issues and approaches for addressing them. Findings and dissemination of results. The SPARHCS assessment culminated in the preparation of a briefing booklet in both Arabic and English, which synthesized all available CS information (MOHP and POLICY, 2004). The briefing booklet was distributed to participants during the October 2004 CS awareness-raising workshop and is available from POLICY. The CSWG planned to use the briefing booklet as the basis for awareness-raising activities and policy dialogue to update stakeholders and politicians on CS issues. Additionally, POLICY prepared a workshop report, highlighting important topics covered and the selection of Egypt’s priority CS issues by workshop participants (POLICY, 2004). Overview of SPARHCS Findings SPARHCS revealed Egypt’s progress in moving toward contraceptive security, including expanded service delivery points for family planning; functional operating systems (procurement, logistics, and 3 Egypt’s national Contraceptive Security Working Group, formed in summer 2004, is composed of individuals from the Population Sector and the planning and finance divisions of the Ministry of Health and Population (MOHP). 3 information); technical capacity for the local production of contraceptive methods; and a growing qualified workforce. SPARHCS also revealed important issues in the areas of service delivery and use; market segmentation; financing; logistics, procurement, and distribution; and policy, leadership, and coordination that Egypt must face to achieve contraceptive security. Select findings from the CS briefing booklet are included below (MOHP and POLICY, 2004). Service delivery and use. In Egypt, 5,727 service delivery points are authorized to provide FP services. Of these, 36 percent are located in urban areas and 64 percent in rural areas—but with uneven distribution. The MOHP operates 86 percent of the units; 6 percent belong to the Egyptian Family Planning Association (EFPA); 2 percent belong to the Ministry of Insurance and Social Affairs (MISA); and the remaining 6 percent belong to the Health Insurance Organization (HIO), the Teaching Hospitals Organization (THO), and trade union clinics. Community health workers associated with the MOHP and NGOs extend the capacity of these facilities, particularly in rural areas. Overall, NGO involvement in the delivery of FP services has decreased over time from 9 percent in 1995 to 5 percent in 2003. Marked regional variation exists in the distribution of commercial pharmacies, with Upper Egypt and the frontiers border having the highest number of people per pharmacy (4,726 and 5,885, respectively) (El-Zanaty et al., 1996; El-Zanaty and Way, 2001; El Zanaty and Way, 2004; NPC, 2003). The availability of methods is good according to Egypt’s Service Provision Assessment Survey (ESPA), which found that 98 percent of the assessed health facilities—including MOHP hospitals, MCH/Urban health centers, rural health units, mobile units, and NGO clinics—offered modern contraceptive methods. The majority of the facilities offered the four most commonly used methods (OCs, IUDs, injectables, and condoms). NGO clinics, however, offered a smaller variety of methods (MOHP et al., 2002). The quality of services could be improved to enhance client satisfaction and increase demand for family planning. While research conducted in MOHP FP facilities found that clients were satisfied with the offered services, but 57 percent felt changes were needed to improve services. The ESPA revealed that the quality of FP services varied by source and method. While FP clientele prefer female providers, a large percentage of physicians offering family planning are men, likely affecting the use of family planning and/or client satisfaction. Interventions could include training to improve the technical and managerial capacity of MOHP staff at different levels of service delivery and improved distribution of health personnel (MOHP et al., 2002; Frontiers in Reproductive Health, 2001). Market segmentation. The MOHP in Egypt has traditionally maintained a policy of free or nearly free FP products and services in the public sector. In actuality, most women pay for their contraceptive methods in the MOHP because the user fee system is almost universally applied. Evidence reveals that MOHP services are reaching the poor but also many of the nonpoor who could afford to pay for family planning. Forty-two percent of MOHP clientele are from the two poorest economic groups, while 36 percent and as much as 58 percent of clientele could potentially pay for family planning (Abdel-Aziz Sayed et al., 2005). This public sector policy results in the continued loss of commercial and NGO sector market shares because these sectors find it difficult to compete with low-cost providers. It will be difficult for the MOHP to serve existing and increasing numbers of FP users with limited resources. To achieve contraceptive security, policies and appropriate strategies are needed to mobilize all potential sources of FP provision, including commercial and NGO sectors, and to identify the clientele that each sector is best positioned to serve. The MOHP needs more effective mechanisms in place to target its resources to poor FP clients and to take action in providing an enabling policy environment for participation of the NGO and commercial sectors. In June 2004, pharmaceutical vendors and the MOHP met and expressed commitment to work collaboratively—an important development since previously the relationship between the MOHP and the pharmaceutical industry had not been successful or amiable. 4 Financing. The MOHP procures contraceptives, mainly OCs from local manufacturers and condoms. At the time of the assessment, the MOHP was receiving only IUDs and injectables from USAID. These two methods accounted for 73 percent of the method mix, and the public sector was the dominant provider of these two methods. Beginning in 2004, the government began purchasing IUDs, followed by the purchase of injectables in 2005, to prepare for the handover of responsibility for financing and procurement of Egypt’s contraceptives. The handover of responsibility will be complete once the last of USAID commodities arrive in the end of 2006. Demand for contraceptives in Egypt is growing at the same time as USAID is phasing out its support. Projections show that by 2017, the expansion of demand will result in an estimated budget requirement for the MOHP of approximately US$30.5 million annually for contraceptives (Contraceptive Cost Study Team, 2003). Logistics, procurement, and distribution. The capacity to accurately forecast contraceptive needs and procure high-quality contraceptives at a reasonable price is critical to contraceptive security. In Egypt, contraceptive needs are forecasted for three years and adjusted every year. The staff of the Logistics Management and Management Information System units is responsible for preparing forecasts, and its reporting and recording system has increased in efficiency since 1988. Procurement plans are based on updated forecasts, inventory levels, losses and adjustments, lead time, and shipping and handling issues (Ainsworth and Dickens, 2004; NPC, 2003). The MOHP contracts with the Egyptian Pharmaceutical Trading Company (EPTC) to distribute, store, and sell contraceptives and to manage the contraceptive inventory and information systems, which the MOHP uses to track contraceptive flow. The distribution of contraceptive commodities is based on monthly consumption reports received from service delivery points and entered into the computer to determine the orders. A list of the quantities to be delivered is sent to the Store Keeper at the MOHP main supply. Stockouts of some contraceptives do occur occasionally, suggesting inefficiencies in the inventory and information systems that could be corrected (Ainsworth and Dickens, 2004). Policy, leadership, and coordination. The high-level political commitment that exists in Egypt should be translated into operational policies that support and create an enabling environment to secure the availability of FP services and commodities. Although the Egypt National Population Policy and Strategies (NPPS) includes clear references on the need for FP sustainability and contraceptive security, the operational policies and regulations do not always address these issues. The creation of the MOHP in 1996 placed the responsibility for public sector FP service delivery with the ministry. The NPC retains responsibility for formulating national population policies and for the population and FP research necessary for policy development. At the time of the SPARHCS assessment, MOHP members of the CSWG had taken the lead in advocating for CS issues within their ministry and among other ministries and sectors, but active involvement was also needed from other ministries in CS dialogue, advocacy, planning, and finance activities. Priority Issues for Achieving Contraceptive Security Through an informed decisionmaking process and a vote, 11 priority CS issues were identified by key stakeholders at the CS Issues Workshop. Issues fell under the areas of financing, coordination and collaboration, logistics, private sector participation, quality of services, awareness raising, pricing, targeting of resources, demand creation, health sector reform, and procurement, with the government taking the lead role in addressing these issues (POLICY, 2004). The below issues are ranked, with the top priority issue listed first. 5 • Mobilize government resources to fully fund the FP program, which includes contraceptives; information, education, and communication (IEC)/behavior change communication (BCC) activities; training; and monitoring and evaluation. • Strengthen collaboration and cooperation among donors, government, and other key stakeholders. • Upgrade and maintain the logistics system so that it will ensure an adequate supply of contraceptives to all levels of the distribution system. • Promote greater participation of the commercial and NGO sectors in achieving the goal of contraceptive security. • Ensure the sustained delivery of high-quality FP services. • Raise awareness about contraceptive security among key stakeholders including civil society and parliamentarians. • Examine and remove pricing barriers to ensure effective functioning of the contraceptive market. • Develop a transparent system for using resources to subsidize contraceptives and services for the poor. • Reduce unmet need and discontinuation rates and improve access to family planning. • Ensure that family planning is adequately addressed in the health sector reform process to enable the achievement of CS goals. • Determine how the phaseout of donated contraceptives will affect the procurement of contraceptives by the government. Lessons Learned Using SPARHCS in Egypt Egypt’s SPARHCS application, which included conducting the assessment and creating a strategic plan, provided important information about the most effective way to conduct CS planning efforts. These lessons can be used for preparing and implementing CS activities. SPARHCS can frame and provide momentum to previous CS activities. In both Egypt and Jordan, SPARHCS did not initiate CS efforts; rather it provided structure and direction for how to move forward with CS agendas, specifically in CS strategic planning. Teams used the SPARHCS framework as the basis for a situation analysis, using available information and data but also determining gaps in information that needed to be filled by conducting new studies or consulting the appropriate stakeholders. National contraceptive security committee fosters ownership of CS activities and moves them forward. Egypt’s CSWG includes representatives from the MOHP, who have taken the lead in advocating for CS issues within the MOHP and among stakeholders from other ministries and sectors. Even though the CSWG is not broad-based and is mostly a core group of MOHP representatives, it has actively involved people from the ministries of finance, education, and planning, as well as NGO and commercial sector groups, in CS dialogue and its advocacy, planning, and finance activities. Such broad-based involvement and interest are critical to achieving contraceptive security in Egypt. 6 Activities and Progress since the SPARHCS Application Since the end of 2004, Egypt’s activities have focused specifically on the how to obtain the required financial resources to replace donor support and how to mobilize stakeholder support for the CS strategic plan. Selected activities and progress include the following: • In December 2004, POLICY/Egypt presented findings and recommendations from the SPARHCS assessment to the Minister of Health and Population, who, on December 25, 2004, brought them to the attention of the ministerial committee for health services and control of population growth. The minister requested government financial resources to compensate for USAID’s phaseout of contraceptive commodity support, taking into consideration the increase in contraceptive demand and the possible price increase. The committee approved a series of activities that were subsequently approved by the prime minister on January 26, 2005, and sent to relevant ministries for implementation. The activities included: o Secure financial resources to compensate for contraceptive supplies that were provided by USAID and to increase strategic stock to avoid possible stockouts based on the needs specified by the MOHP/Population Sector (to be done by the Ministry of Finance); o Encourage local manufacturing of contraceptives; o Examine the possibilities of beneficiary contribution to the cost of services, especially for those who are able to pay; o Exempt all contraceptives imported by the MOHP from all duties and sales tax; and o Negotiate with all international and national agencies to contribute to the purchase of contraceptives, as a first priority. • From March 31–April 2, 2005, POLICY and the MOHP/Population Sector conducted a three-day workshop titled “Contraceptive Security Strategic Plan (CSSP),” which aimed to prepare a CS strategic plan based on the priority topics that evolved from the October 2004 workshop and the careful reconsideration of the CSWG. Twenty-eight participants from multiple sectors attended. The outcome of the meeting was a draft CSSP, identifying the main activities, subactivities, responsible partners (stakeholders), timeframes, and indicators to measure success. Participants consulted the SPARHCS framework as a guide for the creation of the CSSP. • In May and June 2005, POLICY and members of the CSWG, MOHP/Population Sector, MOHP/Financial Department, the Ministry of Finance (MOF), NGOs, and Health Sector Reform (HSR) participated in four meetings to further finalize and consolidate the draft CSSP by identifying information and action gaps. • Advocacy efforts to secure funds for contraceptive commodities culminated when the Minister of Health and Population emphasized the importance of having proper types and quantities of contraceptives and of maintaining adequate strategic stocks to avoid possible stockouts of contraceptive commodities as Egypt assumes full responsibility for contraceptive procurement. The minister also capitalized on the prime minister’s previous approval of allocating national funds for contraceptives by requesting additional funding of US$8.9 million. In response, the MOF approved the allocation of additional funds for contraceptives to the MOHP/Population Sector, amounting to US$1.5 million for 2004/2005 and US$2.8 million for 2005/2006. • In accordance with recommendations of the DELIVER logistics mission carried out in 2004 to assess the contraceptive logistics system, POLICY arranged for two MOHP/Logistics 7 Management Unit staff to take part in DELIVER’s Supply Chain Logistics for Commodity Security course that was conducted in Accra, Ghana, from April 17–May 6, 2005. The course aimed to increase participants’ understanding of and management skills for logistics and contraceptive commodity forecasting. • To enhance the experience of the MOHP/Population Sector in working toward contraceptive security, POLICY organized an observation study tour to Morocco from June 20–26, 2005, for five individuals, including the head of the Population Sector. The study tour allowed participants to learn about Morocco’s successful experience in achieving full responsibility for the procurement and financing of contraceptive commodities since 2000, after USAID’s phaseout of FP program support. Lessons learned and observations will enhance the CSSP’s development and implementation. • In July 2005, in its last quarterly meeting, the Ministerial Committee on Health and Population endorsed the MOHP/Population Sector’s request for establishing a special budget line item for contraceptives. • In July 2005, POLICY assisted the CSWG in consolidating several drafts of the CSSP. The main objective was to ensure that the CSSP is realistic, comprehensive, and establishes clear links with the overall strategic plan for family planning and reproductive health, which was adopted by the MOHP/Population Sector. • To secure the availability and accessibility of required contraceptives at service delivery points based on accurate forecasting of the actual needs, in July and August 2005, the MOHP participated in training to strengthen forecasting capacity. • In October 2005, the CSWG, with assistance from POLICY, determined the financial requirements of the activities in the finalized CSSP. In December 2005, the CSWG and POLICY revised the CSSP to contain costs. • In April 2006, the CSWG will lead a final dissemination of the CSSP and present the process undertaken in its development. Egypt’s commitment to achieving contraceptive security is clear in its ownership of and hard work in implementing solutions to national CS issues. Capacity-building activities taking place in tandem with development of the strategic plan ensure that Egypt will continue to advance its CS efforts in the short, medium, and long term. By maintaining steady stakeholder commitment and working toward the implementation phase of the strategic plan, contraceptive security in Egypt is on the horizon. References Abdel-Aziz Sayed, H., M. Borda, S. Sharma, and B. Winfrey. 2005. Market Segmentation in Egypt: Draft Report. Washington, DC: Futures Group/POLICY Project. Ainsworth,W. and T. Dickens. 2004. Procurement of Contraceptives by MOHP: Findings and Recommendations of Technical Assistance Team. Cairo, Egypt: Ministry of Health and Population (MOHP), USAID, Futures Group/POLICY Project, JSI DELIVER. Contraceptive Cost Study Team. 2003. Estimating MOHP’s Contraceptive Commodity Costs to 2017: Final Report to USAID. Cairo, Egypt: Contraceptive Cost Study Team. 8 EI-Zanaty, F., E.M. Hussein, G.A. Shawky, A.A. Way, and S. Kishor. 1996. Egypt Demographic and Health Survey 1995. Calverton, Maryland: Egypt National Population Council (NPC) and Macro International, Inc. El-Zanaty, F. and A.Way. 2001. Egypt Demographic and Health Survey 2000. Calverton, Maryland: MOHP, NPC, and ORC Macro. El-Zanaty, F. and A. Way. 2004. Egypt: Interim Demographic and Health Survey 2003. Cairo, Egypt: MOHP, NPC, El-Zanaty and Associates, and ORC Macro. Frontiers in Reproductive Health. 2001. Improving Client Provider Interaction (CPI): Some Basic Findings. Cairo, Egypt: Population Council/Frontiers in Reproductive Health. MOHP and POLICY. 2004. Achieving Contraceptive Security in Egypt: Briefing Document. Cairo, Egypt: POLICY/Egypt. MOHP, El-Zanaty, and ORC Macro. 2002. Egypt’s Service Provision Assessment Survey (ESPA). Cairo, Egypt: MOHP. National Population Council (NPC). 2003. Annual Statistical Report. Cairo, Egypt: NPC. POLICY Project. 2004. Workshop Report: Contraceptive Security in Egypt: Basic Issues, October 11-13, 2004. Washington, DC: Futures Group/POLICY. POLICY Project and CATALYST. 2002. Contraceptive Security Cost Study. Cairo, Egypt: POLICY and CATALYST. Population Reference Bureau (PRB). 2005. World Population Data Sheet. Washington, DC: PRB. Zohry, A. 1997. “Population Policies and Family Planning Program in Egypt: Evolution and Performance.” Pp. 194–211 in CDC 26th Annual Seminar on Population Issues in the Middle East, Africa, and Asia. Cairo, Egypt: Cairo Demographic Center. 9

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