ICPD+20: Status of Sexual and Reproductive Health and Rights in the Middle East and North Africa RECLAIMING & REDEFINDING RIGHTS Civil Liberties Program First edition / September 2013 Design and printing: www.reemnaeim.com Egyptian Initiative for Personal Rights 6 Dar El-Shefa St., Ground Floor, Garden City, Cairo, Egypt. Tel/fax: + (202) 279 60 158/ 279 60 197 www.eipr.org - [email protected] All printing and publication rights reserved. This report may be redistributed with attribution for non-profit purposes under Creative Commons license. CONTENTS IV 01 List of Tables Chapter 1 Introduction IV 05 List of Boxes Chapter 2 Contextualizing Women’s Rights and Health Expenditure VI Acknowledgements 27 Chapter 3 Reproductive Health and VII Rights Executive Summary 61 VIII Chapter 4 Acronyms and Sexual Health and Rights abbreviations 91 Chapter 5 Voices from the Region 95 Chapter 6 Conclusion and Recommendations LIST OF TABLES 9 Table 1 Country reservations to the CEDAW 73 Table 23 Anti-rape laws in six countries in the MENA region 13 Table 2 Comparison of HDI values and ranks, IHDI values, 74 Table 24 Anti-marital rape laws in six countries in the MENA MPI values and GII values and ranks region 13 Table 3 Gender Inequality Index 75 Table 25 Anti-FGM laws in six countries in the MENA region 14 Table 4 Seat in parliament held by women (% of total) 75 Table 26 Percentage of women subject to FGM in six countries in the MENA region, (1997–2007) 14 Table 5 Girls’ share of primary, secondary and tertiary enrollment 76 Table 27 Anti-sexual harassment laws in six countries in the MENA region 15 Table 6 Anti-domestic violence laws in six countries in the MENA region 79 Table 28 Anti-trafficking laws 17 Table 7 Male and female labor force participation rate LIST 18 Table 8 Trends in healthcare financing (2000, 2005, 2010) OF 29 Table 9 Maternal deaths per 100,000 live births, BOXES achievement of ICPD targets and lifetime risk of maternal death (1995, 2003, 2008/2011) 20 Box 1 Health Financing in Egypt 30 Table 10 Skilled health attendants at birth 21 Box 2 Health Reform in Turkey 32 Table 11 Antenatal care coverage in six countries in MENA 42 Box 3 Post-abortion Care in Egypt region 33 Table 12 Tetanus protection at birth in six countries in MENA region 37 Table 13 Grounds on which abortion is permitted 39 Table 14 Estimates of unsafe abortions and related maternal deaths 43 Table 15 Total fertility rates in six countries in the MENA region 45 Table 16 Contraceptive prevalence rates and method selection 46 Table 17 Male contraception as percentage of total contraception 48 Table 18 Unmet need for contraception (1995, 2003, 2008) 51 Table 19 Cervical cancer risk, mortality and incidence in six countries in the MENA region 65 Table 20 HIV and AIDS estimates and date (2001, 2009) 68 Table 21 Adults and children with advanced HIV infection receiving ART, (2009) 70 Table 22 Age of marriage in six countries in the MENA region Monitoring Report Reclaiming & Redefining Rights thematic studies 4 Status of Sexual and Reproductive Health and Rights in the September 2013 Middle East and North Africa (by EIPR) ACKNOWLEDGEMENT execUtiVE SUMMARY This report was researched and drafted by Maissan Hassan, thanks to Sai Jyothirmai Racherla for her valuable support and The year 2014 was meant to be the year that ended the Program increase in the level of sexual violence against women. Dalia Abd El-Hameed and Sherif Arafa, under the supervision guidance throughout the various research stages. EIPR would of Action adopted by the Cairo Conference for Population and of EIPR’s Deputy Director Soha Abdelaty. Mandy McClure also like to acknowledge Malin Sundgren, Aurora Ellis, Hanna Development (ICPD) in 1994. The document was a paradigm Given the diversity of socioeconomic conditions in the MENA copyedited this report. King and Sarah Hassan for their research assistance. shift in understanding and framing reproductive health and region, it is difficult to make categorical statements about the rights and prioritizing individuals’ rights to choose and make situation of reproductive and sexual health and rights. Yet, in The report was done in collaboration with Asian-Pacific Egyptian Initiative for Personal Rights (EIPR) is an independent decisions with regards to their own bodies. Now that the many countries disparities in access to reproductive healthcare Resource and Research Center for Women (ARROW). EIPR Egyptian human rights organization that was established in 2002 General Assembly extended the PoA indefinitely, and will persist, where poorer, less educated and rural woman face would like to acknowledge Dr. TK Sundari Ravindran for to promote and defend the personal rights and freedoms of review country progress at its 2014 session, it is the right many barriers to adequate and affordable healthcare services. reviewing this report and for her valuable inputs. Special individuals. moment to evaluate the extent to which different countries in In most MENA countries, women and young people are the region implemented the PoA and how this has changed the excluded from decision-making circles, which is reflected in the realities lived by women and youth regarding their sexual and gender-insensitive policies adopted by these states. reproductive health and rights. Adopting a progressive agenda for post-2014 will definitely In the MENA region, acknowledging reproductive rights in a UN positively influence women’s and young people’s lives and consensus document has greatly contributed in enhancing the make governments more accountable for the health and lives of countries’ policies especially in maternity care, family planning their citizens. It will also help to integrate women and youth in services and HIV/AIDS. Yet, cultural and religious discourses designing, implementing and monitoring policies that influence still play a major role in holding back sexual rights especially their reproductive health and will provide guidance on achieving for young people. Women’s autonomy over their bodies is reproductive justice. still a highly debated issue because of the deeply embedded patriarchal culture, which is also reflected in an unprecedented VI VII Monitoring Report Reclaiming & Redefining Rights thematic studies 4 Status of Sexual and Reproductive Health and Rights in the September 2013 Middle East and North Africa (by EIPR) ACRonYms AND ABBREViations AIDS Acquired immunodeficiency syndrome HRW Human Rights Watch (NGO) OOP Out of pocket VCT Voluntary counselling and testing ANC Antenatal care HTP Health Transformation Programme OC Oral contraceptive WB World Bank ART Anti-retroviral therapy IARC International Agency for Research on Cancer OECD Organization for Economic Cooperation and WHO World Health Organization Development ARV Anti-retroviral drugs ICCPR International Covenant on Civil and Political WID Women In development Rights OPT Occupied Palestinian territory CREDIF Centre for Studies, Research, Documentation and YS Young people sexuality Information on Women IDU Injecting drug users PCBS Palestinian Central Bureau of Statistics CEDAW Convention on Elimination of All Forms of IEC Information, education and communication PLWHA People living with HIV/AIDS Discrimination Against Woman ICESCR International Covenant on Economic, Social and PLHIV People living with HIV CROC/ CRC International Convention on the Rights of the Child Cultural Rights PNA Palestinian National Authority CRC Committee on the Rights of the Child ICPD International Conference for Population and PvtHE Private health expenditure Development CRR Center for Reproductive Rights (NGO) PAB Protection at birth ICPD PoA International Conference for Population and CPR Contraceptive prevalence rate Development Program of Action PAC Post-abortion care CSE Comprehensive sexuality education ICPD+5 ICPD follow up conference for implementation of SBA Skilled birth attendance DHS Demographic and health survey ICPD recommendations SCAF Supreme Council of the Armed Forces (Egypt) D&C Dilatation and curettage IHDI Inequality-adjusted Human Development Index STI Sexually transmitted infection EmOC Emergency obstetric care IUD Intra-uterine device SRHR Sexual and reproductive health and rights EU European Union KCR Kuwait Cancer Registry TFR Total fertility rate FGC/M Female genital cutting or mutilation LGBT Lesbians, gays, bisexuals, transsexuals THE Total health expenditure FP Family planning MARP Most-at-risk populations UHI Universal health insurance FSW Female sex workers MDGs United Nation’s Millennium Development Goals UN United Nations GBV Gender-based violence MENA Middle East and North Africa UNDP United Nations Development Program GCC Gulf Cooperation Council MMM Maternal mortality and morbidity UNESCO United Nations for Education, Scientific and GGHE General government health expenditure MMR Maternal mortality ratio Cultural Education GDP Gross domestic product MNT Maternal and neonatal tetanus UNFPA United Nations Population Fund GHIS General health insurance scheme MPI Multidimensional Poverty Index UNICEF United Nations Children’s Fund GDI Gender Development Index MSM Men who have sex with Men UNIFEM United Nations Development Fund for Women GII Gender Inequality Index MVA Manual vacuum aspiration UNODC United Nations Office on Drugs and Crime GEM Gender Empowerment Measurement NCRPE National Cancer Registry Program in Egypt UN OHCHR United Nations Office of the High Commissioner for Human Rights GTF Genital tract fistula NCW National Council for Women UNRWA United Nations Relief and Works Agency