At Home and in South-South Partnerships, Tunisia Expands Its Commitment to Reproductive Health

By Janet McMahon

The 1994 United Nations International Conference on Population and Development (ICPD) in Cairo was marked by controversies, including the anti-family-planning alliance of Pope John Paul II and then-Iranian President Ali Akbar Hashemi Rafsanjani.

Less noticed at the time, but of more lasting impact, was the creation of Partners in Population and Development, a South-South collaboration of 10 developing countries “internationally recognized as having developed effective population policies...and willing to share their experience and expertise with other developing countries.”

Not surprisingly, Tunisia is one of the 10 founding countries—the others being Bangladesh, Colombia, Egypt, Indonesia, Kenya, Mexico, Morocco, Thailand and Zimbabwe. China, Indonesia, Pakistan and Uganda became members in 1998. Again not surprisingly, the chair of this innovative partnership is Dr. Nabiha Gueddana, general director of Tunisia’s National Institute of Family and Population (ONFP).

At the time of the Cairo conference, the ONFP already had been in existence for two decades. Established in 1973 as the “National Family Planning and Population Board,” it was charged with carrying out the Tunisian government’s maternal health program.

In the mid-1970s, when Tunisia’s birth rate was 2.6 percent, with an average of 5.79 children per woman, the emphasis was placed on lowering that figure. Some 20 years later, it has dropped to 1.7 percent, with an average of fewer than three children per mother.

Tunisia’s trademark ingenuity and flexibility have meant that over the years the focus of its efforts has shifted. As the ONFP’s director of medical services, Dr. Salah Meddebexplained the first stage of the national program was focused on “purely demographic” concerns. “In the context of Tunisia’s then-precarious economic and social conditions, the emphasis was on limiting births.”

The following decade saw a shift in emphasis to an overall concern with family health, focusing on “the spacing of births rather than the number of children,” Dr. Meddebsaid. Indeed, this shift has been both a cause and a result of the program’s success.

Ben Mahmoud Salah, who heads the National Office for Family and Population in Tunisia’s rural Kairouan province, described local residents’ reaction to the government’s initial message. “After several trials to promote the image of a couple with two or three children, we began to receive negative reactions...This was at a time when families with six or seven children were common,” he explained. “The reactions gave us the impression that these people did not appreciate being considered as examples of failures! The message of the health requirements for both mother and child then became more acceptable.”

“N’Sabbar!” is a Tunisian phrase meaning, “I am patient, I try to be patient!” Now it has come to mean, “I plan my births.”

As one young mother at a mobile clinic in Kairouan told a visitor, “I have decided to take the contraceptive injection in order to allow my son to have better health. Look how pale he is...I must n’sabbar!”

The colorful and well-attended mobile clinics make reproductive health a reality for rural women who live too far from clinics in town. In addition to availing themselves of birth control devices such as IUDs (the most popular method) and Norplant, women can also receive such services as pre- and post-natal care, infertility consultations, and screenings for breast and cervical cancer.

Tunisia’s youth are considered a critical component to the country’s success in its efforts toward family and reproductive health. Working with the Boy Scouts and other Tunisian NGOs, the ONFP has established a “Youth and Reproductive Health” project to educate young people on such issues as preventing sexually transmitted diseases, including AIDS. A cartoon character named “Rifel” (who looks somewhat like Caspar the Friendly Ghost) explains the use and benefits of condoms to young Tunisians, to whom Rifel is a popular, everyday figure.

Particularly since the 1994 Cairo conference, Tunisia has taken the “global” approach of integrating family planning into basic health services, as the mobile clinics exemplify. And particularly since the 1996 Mexico meeting of Partners in Population and Development (which is headquartered in Bangladesh), the ONFP has “reinforced its activities in South-South cooperation with French-speaking countries and the Arab world.”

The goals of the overall South-South exchange are fourfold, according to the ONFP’s Bel Haj Aissa Adnene: the integration of family planning and reproductive health; AIDS prevention and care; adolescent reproductive health; and lowering maternal mortality and morbidity. The Partners cooperate in disseminating information, developing new projects, identifying new funding sources (current major funders include the World Bank and the Rockefeller and Hewlett Packard foundations), and strenthening the network among members.

Among Tunisia’s many contributions toward these objectives is its International Training Program, which instructs health care professionals from Africa and the Arab world. Participants receive what Kairouan’s Ben Mahmoud Salah describes as their “theoretical training” in such subjects as service delivery, communications, management, and technology at the main training center in Tunis. They may then undertake additional study at regional training centers such as the one in Kairouan, which employs supervising midwives to provide “close follow-up and management training” in a clinical setting.

“We use all possible means to share our experiences with our African colleagues,” Salah says, describing one such program, “while simultaneously learning a lot during our interaction with them.”

Other South-South programs include study and familiarization tours for high-level health and economic planning officials and associations, and technical assistance and transfer of expertise, whereby ONFP managers have visited such countries as Guinea, the Ivory Coast, Togo and Benin to assist in implementing training strategies that were formulated with Tunisian assistance. Additionally, in July 1997 Tunisia hosted the First Francophone African Conference for South-South Collaboration for Reproductive Health and Development.

In yet another example of the various levels at which this partnership works, Partners chair and ONFP director general Dr. Gueddan has consulted with UNAIDS executive director Dr. Peter Piot regarding issues affecting reproductive and family health. Gueddan also participated in the September 1997 conference in Paris of French-speaking parliamentarians, resulting in the formulation of the Paris Appeal urging these legislators to support reproductive policies and programs in their respective countries.

At the more local level, after completing their training in Tunisia, health workers from developing countries often face obstacles to the implementation of reproductive health programs in their own countries. Ben Mahmoud Salah notes that their training workshops anticipate some of these restrictions. “However,” he admits, “certain problems can only be overcome by the involvement of policy- and decisionmakers. My advice to these trainees is simply that ‘whenever faced with a problem that is not within your ability [to correct], do not hesitate to point this out wherever you might be.’”

The follow-up does not necessarily stop there, however. Although “to intervene at the level of policymakers of other countries is beyond our ability,” Salah says, “during training with us and prior to the participants’ departure, we usually prepare together, at their request, letters for policy- and decisionmakers requesting they pledge to improve our trainees’ future working environment.”

Ben Mahmoud Saleh perhaps best sums up the philosophy of the Partners in Population and Development when he says, “Nations must be ready to acquire the know-how of others, and this applies to us as well.” Both in theory and in practice, this is a philosophy Tunisia clearly takes to heart.