Time for self-reliance?

Surveying a quarter century of US assistance, Gihan Shahine examines the contribution of USAID population and health programmes and the prospects for their sustainability

It is a story familiar to many women in rural and impoverished areas in Egypt. Unable to give birth to a boy, Latifa was forced by her mother-in-law into a series of pregnancies that produced 11 girls -- four of whom died shortly after birth.

To make ends meet, Latifa had to live with her mother-in-law in a one-room shack in the shanty area of Berak Al-Kheyam. "I regret having bowed to my mother-in-law's wishes," Latifa laments. She explains the loss of so many children: "I was worn out by the recurrent pregnancies." She could also blame malnutrition, lack of maternal care and poverty.

When asked about family planning, contraception, reproductive health and birth-spacing, she knows the jargon by heart. There is a family planning clinic nearby. But in her case, social pressure proved insurmountable.

Latifa uses contraceptives now, but not many of her neighbours do. "People love children, who bring rizq (livelihood) and are a good asset when one gets older," Latifa explains.

Social stereotypes have been a major challenge to the successful implementation of the Egyptian government's population policies and, accordingly, to USAID's programmes since they began in 1978.

According to USAID officials, their main role is assisting the Egyptian government achieve national goals through financial and technical assistance. The government credits the agency's contribution with the success of its national policies. The population and health sector has, in fact, been the largest of all USAID areas of assistance -- and one that has provoked heated controversy. Many experts criticise the "waste of the agency's funds," "US interference" in Egypt's population policies and the agency's alleged "supply of unneeded commodities and expired contraceptives."

Assessing the agency's role is made difficult by people's reluctance to talk about such a highly sensitive and politicised issue. Many of those who spoke to Al-Ahram Weekly asked that their names be withheld. USAID officials themselves would only make off-the-record statements.

In the early 1930s, non-governmental organisations (NGOs) took the initiative in launching family planning programmes in Egypt, waging battles against social stereotypes. Since the early '80s, with Egypt focusing on reducing its population growth rate, the government tried to increase awareness of over-population and of the use of contraceptives. By 1987, the Ministry of Health had established 3,200 rural health clinics and 4,200 family planning units.

Expanded immunisation: a feather in USAID's cap
photo: Barry Iverson

In 1975, USAID began working in the health sector in Egypt. During the 1970s and early '80s, it aimed to expand access to general health services for the rural and urban poor. Reducing infant mortality rates was found to be crucial in cutting fertility rates: women tend to have more children when their children are apt to die. US assistance led to expanded immunisation, control of diarrhoeal diseases (once the major cause of infant death), better treatment of acute respiratory infections (the second highest cause of infant death), improved training for traditional midwives and a national neonatal care programme.

USAID launched a medical school insurance programme, covering 12 million school children aged between 11 and 19. The agency helped the government develop an anaemia-prevention project in Upper Egypt, resulting in a 20 per cent reduction in anaemia cases over the past three years.

In line with the government's population policy, initial USAID programmes, from 1978 to 1989, centred on disseminating information about family planning in cooperation with the State Information Service. USAID contributed by hiring foreign advertising firms to develop new advertisements and brochures, providing better counselling and training religious and community leaders to help eliminate religious misconceptions about birth control. USAID was also involved in developing the necessary infrastructure and in improving the supply of contraceptives.

The agency's later programmes sought to ensure sustainability. Efforts were made to enhance the Ministry of Health and Population's (MOHP) capacity to plan and manage health services, establish an information system and upgrade the skills of medical staff.

Since the 1994 United Nations International Conference on Population and Development (ICPD), Egypt changed its population strategy to integrate family planning within reproductive health programmes. The ICPD Action Programme stressed that women's health care was of pivotal importance in solving over-population problems and was an integral part of Egypt's social, economic and environmental development plans. This led to a broader strategy of comprehensive health care for women and children and to the integration of the Ministry of Population within the Ministry of Health in 1996.

But how have USAID-funded projects affected the lives of women like Latifa? At least Latifa's girls insist they will not have more than two children each. They are educated and aim at a better life than that of their mother. Latifa herself now regularly visits the family planning unit in the area, attending seminars where she receives sex education (delivered in a religious context) and information on reproductive health and maternal care. All of the children in her district are vaccinated. "Many of my neighbours are also taking literacy classes and are much more aware than I was when I got married," Latifa says.

This is a notable improvement. In the past, rural women almost never went to the doctor and many gave birth at home. Family planning programmes were challenged by tradition and religion. Today, family planning is making headway in Egypt, though it still faces many challenges.

The 2000 Egyptian Demographic and Health Survey (EDHS) quantifies the progress made. The number of married women using contraceptives reached 56 per cent in 2000 -- more than double the 1980 rate. The total fertility rate (TFR, the average number of live births per woman during her lifetime) has fallen by a third -- from 5.3 in 1980 to 3.5 in 2000. Egypt's overall infant mortality rate declined from 63 per 1,000 births in 1995 to 44 in 2000, representing a reduction of nearly 30 per cent.

Such impressive results, however, are challenged by the fact that population growth has stood at 2.1 per cent since 1996, after a promising drop from 2.8 per cent in 1986. A Population Reference Bureau report indicates that for a population to cease growing, couples must have an average of two children and warns that, in Egypt, "it may be that two children will never be the norm."

USAID officials concede that there are still challenges to achieving the long-term objective of 74 per cent contraceptive use and 2.05 TFR by 2016. Still, they are proud of the fact that three- quarters of the Egyptian population now accepts the usefulness of family planning.

"There has, no doubt, been a positive change in attitude," notes Sanaa El-A'sar, secretary-general of the Cairo Association for Family Planning and Development and a former USAID project consultant. "More women accept contraception now, although their number does not exceed 52 per cent in Cairo and far less in rural areas and Upper Egypt. Still, that is fair progress."

But to what degree is USAID actually responsible for that progress?

USAID officials point to the EDHS data as an indication of the success of their programmes, though they also credit the government's support and contribution. Many health and family planning experts, however, claim that the agency's role has been marginal: "Too much jargon with little solid contribution," one expert says.

"USAID projects are piecemeal and, more often than not, target the lowest of our priorities. [...] We need money to upgrade our services and attract personnel," El-A'sar argues. "But what we actually get is short-term training for a couple of our physicians, which is not what we need. We need more physicians, cars and money to maintain equipment and carry out several community activities."

Paul Basch's Textbook of International Health (Oxford University Press, 1990) says that "USAID has been met with frequent criticism from both sides" (Americans and recipients) and that the effectiveness of their programmes has been "less than optimal." American criticism emphasises "inefficiency, excessive dependency and ingratitude on the part of the beneficiary," while recipients "claim donor hypocrisy, excessive self- interest, export-dumping, restrictive purchase agreements, arrogance and new colonialism."

Basch explains that among its reasons for launching population and health projects in Egypt, USAID sought to gain information about diseases such as bilharziasis, trachoma and malaria. Developing countries are attractive for conducting studies, as costs are low and administrative supervision is relatively lax, making trials of contraceptives and pharmaceuticals easier.

Speaking to the Weekly, several physicians and NGO representatives alleged that some contraceptives and vaccines, which USAID officials describe as among their major contributions, were brought to Egypt for experimentation purposes. Some had already expired, were nearing their expiry dates or were legally prohibited in the US. Government officials refute that claim: "All drugs are carefully examined before use."

Medical ethics aside, USAID projects have been contested on financial grounds. The agency has committed a total of $500 million to population and health projects. Many NGO members and physicians, however, told the Weekly that a huge part of USAID funding has been wasted on the purchase of unneeded goods, expensive training and foreign consultants.

Training often seems to be a poor investment: it is usually short-term and superficial. No follow- up training is conducted, one source complains. Foreign consultants are very costly and often of little use.

"Short-term foreign consultants are unacquainted with our culture and problems. They usually leave tomes of proposals in their wake, which may end up in the dark confines of officials' drawers," El-A'sar charges. She adds that USAID requires that goods be bought only in the US or Egypt, which can result in higher costs.

Behind the criticism of USAID is general public resentment of US interference in population policies. There is a sense, as one source puts it, "that a foreign conspiracy is targeting Egypt's manpower assets."

USAID projects, however, are designed in collaboration with Egyptian experts and government officials who approve the details before implementation. The targets of the projects are those of the national population policy, USAID officials insist.

Why, then, would the government allow unneeded expenditure?

"Technical assistance (training and consultancy) and purchase restrictions are regulations all recipient countries have to abide by," an official says, preferring anonymity. He adds that it is up to the government, not the donor, to provide physicians and facilities. "Lately, however, costs have been rationalised, with more use of Egyptian products and consultants. Training has also proved very useful."

USAID, he adds, contributed significantly by providing information technology as well as ambulances, office equipment and the like. "Still, the US contribution is marginal when compared to that of the ministry," he quickly notes.

But for Maher Mahran, professor of gynaecology at Ain Shams University, chairman of the National Population Council and former minister of population (before the ministry merged with the Ministry of Health), the US contribution has been significant. He denies that US funds have been wasted. Once the government approves a USAID project, he explains, its budget becomes public and "every single penny is put to ultimate use." There is no place for luxuries, according to Mahran.

"USAID has introduced a new system, helped with capacity building, introduced information technology and furnished us with an excellent base of research -- all besides infrastructure," Mahran says. "How, then, can we deny their significant contribution or claim waste of funds?"

The Healthy Mother/Healthy Child project, to which the ministry contributes 50 per cent, is a case in point. Before the project was launched in 1996, studies indicated that there was no standard protocol or training programme for obstetric and maternal cases. Poor prevention and control procedures were observed in the management of obstetric cases. High mortality rates among women were recorded.

"Today, infant, child and maternal mortality rates have markedly dropped thanks to the project and the increase in literacy levels among women," says Ali Abdel-Meguid, deputy chief of John Snow Inc, a USAID-funded private consultancy firm responsible for the project. "Capacity building and establishing systems and protocol have globally proven essential in improving health care."

With USAID phasing out its assistance to Egypt, concern is mounting over the fate of these projects. Both Mahran and Abdel-Meguid are optimistic. Egypt already provides physicians, facilities and, now, almost all vaccines. The ministry now contributes two-thirds of all projects' budgets.

By 2009, USAID will have already provided the two most expensive elements in the population and health programmes: capacity building and system development. USAID is working closely with professors of obstetrics and gynaecology to develop a medical school undergraduate curriculum in family planning and reproductive health. Such an approach will reduce the burden of training 5,000 physicians annually by the Ministry of Health and Population.

"It is definitely high time that we become self- reliant," Mahran concludes.

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		Al-Ahram Weekly Online 21 - 27 June 2001 Issue No.539
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