Country Statement on Population Matters, policies and intervention on "reproductive rights and health, with special Reference to HIV/AIDS"

REPUBLIC OF SOUTH AFRICA

Presented by WESLEY NIMROD MALEBO To The Fourth Meeting of the Follow-up Committee on the Implementation of Dakar/Ngor Declaration and the International Conference on Population and Development Programme of Action, Younde, Cameroon, 28-31 January 2002

1. Introduction

South Africa's re-introduction into international relations and therefore a full member of the community of nations, resulted in active participation in proceedings of world organisations amongst others the Dakar/Ngor Declaration and Programme of Action of the International Conference on Population and Development. Indeed, this active participation and leading role in regional affairs was demonstrated by South Africa `s initiative of the concept of African Recovery Programme alongside with Nigeria and Algeria, which merged with Omega Plan of Senegal to form New African Initiative, otherwise known as the New Partnership for Africa's Development (NEPAD)

The New African Initiative is based on the determination of Africans to free themselves and the entire continent from malaise of underdevelopment and exclusion in a globalising world. African continent is plagued with poverty, disease, backwardness, dependence, huge debts, and conflicts. This African initiative is geared precisely at reversing such a predicament that Africa finds itself. Africa has both human and in particular non-human resources. The dilemma facing Africa is how to mobilise such resources rationally and properly for the benefit of the poor majority. The Programme therefore calls for bold and genuine leadership that will extricate the continent from the scourge of poverty and underdevelopment.

South Africa, s new democracy and the beginning of active participation in international events coincided with the holding of the International Conference on Population and Development in 1994, in Cairo, Egypt.

The new democracy enshrined in world thinking brought in new dimension in population and development. Of importance is the extent to which women's inputs and choices on reproductive health is recognised. As such more and more concerns are raised on the emancipation of women from historically oppressive mechanism. UNFPA through its executive, supports the liberation of women. This is expressed in a statement made at the Expert Consultation for the African states on Operationalisation of Reproductive Health in Addis Ababa on 25-30 February 1997 in which Dr Nafis Sadik argued that women have been trapped and that there is requirement for population programme to actively engage in process that seek to liberate women to create more options and for women to take charge of their reproductive rights. This argument is further supported by the Beijing Platform of Action and CEDAW. Furthermore ICPD chapter 7 makes emphasis on the need to recognise couples and individual's choices in determining numbers of births and the spacing thereof.

In general there seems to be widespread agreement that fertility began to decline among all the major population groups in South Africa prior to the end of apartheid. This occurred amidst the impoverishment of millions (especially African women), stark inequalities and the disempowerment of women. Although South Africa has undergone a dramatic political transition in the last decade, many of the distortions and dynamics introduced by apartheid continue to reproduce poverty and perpetuate inequality. The classification of South Africa as a middle income country, indeed masks its starkly contrasting living conditions. Poverty seems to affect those in rural and informal settlements or in the periphery of urban settlements. As any other.........poverty seem to the majority of population in particular black women and children.

Substantial disparities also exist on the basis of sex.  Although the enrolment rates at all educational levels are estimated to be slightly higher for females (79.6 per cent) than for males (77.1 per cent), and adult literacy rates are almost equal (80.8 per cent for females, 81.3 per cent for males), the income share of females is only 30.5 per cent of total income.  The average income of female-headed households is about half that of male-headed households.  Women are also underrepresented in the decision-making structures of both the government and the private sector.  The incidence of violence against women is high, with an estimated average of one rape every 83 seconds.  Although the Constitution guarantees equality between the genders in all aspects of life, many administrative and cultural practices still discriminate against women.  An affirmative action policy to redress past inequities is gradually evolving.

In recognition of the wide disparities in socio-economic development in the country vis-à-vis the population distribution, UNFPA endorses the Government's policy to target the Northern Province, Eastern Cape and Kwazulu Natal as the provinces most in need of assistance.  These provinces are estimated to house just under half of the country's total population; 70 per cent of these people live in non-urban areas compared to the national average of 46 per cent.  Unemployment rates are highest in the three provinces.  Northern Province and Eastern Cape are among the provinces with the highest rates of teenage pregnancy; Kwazulu Natal has the highest rate of pregnant women with HIV/AIDS.

Development efforts by the Government on all fronts are being seriously hampered by the high prevalence of HIV, estimated at about 14 per cent among the general population and 22.4 per cent among pregnant women.  The 14 per cent prevalence in 1999-2000 is expected to increase to between 20 and 23 per cent in 2005 and to 22 to 27 per cent by 2010.  This would imply an increase in the infant mortality rate to over 60 per 1,000 by the end of the decade.  Thus, while the birth rate has been dropping over the years, partly because of the high CPR, the death rate in the last inter-censal period increased from 11 to 14 per 1,000 and is expected to continue to increase.  The HIV/AIDS pandemic is expected to cut average life expectancy from 56.5 to 40 years by 2010.  All this is expected to lead to a reduction of annual population growth to 0.4 per cent in 2010, when it could have been expected to be 1.4 per cent without AIDS.  By 2010 the proportion of the infected workforce could increase from 11 per cent to 21 per cent and the number of AIDS orphans could rise from 150,000 to 2 million.

Persons under the age of 20 constitute 44 per cent of the national population.  High unemployment and violence have increased their vulnerability to HIV.  Most at risk are black female youths.  In 2000, approximately 23 per cent of young people under age 24 were reported as being HIV-positive.  To address this overwhelming concern, the national strategic plan for HIV/AIDS and STI prevention and control (2000-2005) has been formulated.  The policy focuses on facilitating and supporting behavioural change.

The Government adopted a national population policy in 1998.  The goal of the policy is to bring about desirable changes in the determinants of the country's population trends so that they are consistent with the achievement of sustainable human development.  The policy has three major objectives: to systematically integrate population factors into all development policies and plans at all levels and within all sectors; to develop and implement a coordinated, multisectoral and interdisciplinary integrated approach for the planning, implementation and management of development programmes; and to generate reliable data on demographic and related socio-economic indicators to guide policy and programme interventions.

Post- Apartheid South Africa has entrenched provisions of reproductive rights in the new constitution. With most constitutions, provisions of reproductive rights are in the form of general rights-to equality, freedom and security of the person dignity, privacy, freedom of conscious and the right to life - the South African constitution specifically refers to reproductive rights.

The South African population policy1 argues that the basic demographic factors fertility, migration and mortality are an integral part of poverty prevalence in the country. These demographic factors cannot be seen in isolation from social factors such as education, unemployment, poor health and housing quality and their interrelationships with poverty. Thus, on the one hand fertility declines as a result of the impact of HIV/AIDS but poverty persists. This is in stark contrast to the experience in other parts of sub-Saharan Africa, where poverty usually goes hand in hand with high fertility. This report further investigates issues around lower fertility, increased exposure of women to sexual abuse and the right to have control over their reproductive choices.

2. Overview of demographic and Socio-economic situation and trends

What is fertility transition

The fertility transition that forms part of the overall demographic transition theoretically follows a particular pattern. It is a generally held view that fertility declines is faster under conditions of a modern economy and higher urbanisation. Enhanced status of women also leads to faster fertility decline. As women pursue education, they tend to postpone childbearing until they are older and therefore have fewer children in their remaining fertile years. Also, women's involvement in paid employment outside the house tends to prohibit large families. High living standards similarly are inversely related to fertility; at higher income levels, women have smaller families. For this reason, high levels of poverty are generally associated with high fertility. Thus improvement in the status of women and poverty alleviation are regarded as two prerequisites for fertility decline.

Reports on the Sunday World Newspaper of 2nd December 2001 in South Africa page 23 states that: 100 new patients are admitted in Gauteng Province hospitals and that 200 000 have occurred in 2001 the majority of these deaths are reported to be aged between 24 and 44. The implication therefore is that the fertility is bound to decline, while at the same time there is an increase on children orphaned as a result of Aids pandemic.

3 Past history of South Africa's fertility compared to Sub-Saharan Africa

Figure 1 clearly illustrates that the South African fertility rate2 is significantly lower than that of other countries in Southern and East Africa. A steady decline in fertility in developing nations took place in the late 1980s and 1990s, especially in the regions of Asia and Latin America. In contrast, Africa and particularly sub-Saharan Africa still lag behind in fertility terms.

The primary cause of the relatively high fertility of the sub-Saharan African region can be ascribed to the economic, socio-cultural and family norms and values that have developed over centuries.4 Women and children provide the bulk of agricultural labour in mainly rural sub-Saharan Africa; the need to work the land is seen as a determining economic factor in the evolution of social structures that resist fertility transition. In the African tradition, survival of children means more land to the extended family. The high levels of poverty and lack of economic opportunities outside of agriculture perpetuates the dependence on the land in much of sub-Saharan Africa. High priority is thus placed on a woman's fertility. Women are almost as afraid of being rendered functionally infertile by the death of all their children as they are of bearing none. Female sterilisation and reversible contraceptive methods are viewed with suspicion. The result is that family planning programmes are less popular in sub-Saharan African and contraceptive prevalence rates can be as low as 10%.5

4. HIV/AIDS intersection with Gender based Violence and Poverty:

Women's vulnerability to HIV/AIDS stem from a range of social, economic, biological, cultural and legal factors (Whelan D, Gender and HIV/AIDS: Taking stock of Research and Programs. UNAIDS 1999).

In the UNAIDS Report on the Global HIV-AIDS epidemic, June 2000 the following is reflected

The hearings found that language e.g. Mother to child transmission can reinforce the blaming in society's mind and does not convey the full picture that it is Parent to Child Transmission (PTCT). The fact as reflected above is that most women are infected by a male partner to whom they are faithful and this is how women then transmit it to their babies. The Committee recommends that the PTCT be used instead of MTCT.

5 The Gendered Economic and Political Reality:

Across the world women have

*less access to power, wealth and resources than men (in South Africa, African women are the majority of the poorest and will therefore benefit most from the eradication of poverty through employment creation and a strong social security system)

*less ownership of land and property than men (in South Africa, African women are the majority of the homeless and landless). One of the most important pieces of legislation in this regard, ``The Customary Law on Inheritance and Succession is yet to be passed.

*inferior legal status to men (South Africa faces the challenge of translating its excellent legislative framework in relation to the rights of women as well as in relation to HIV-AIDS, to lived reality through its judiciary, its police services and public awareness and commitment)

*minimal or non-existent representation on decision-making bodies (while South Africa's Parliament has led the way in ensuring 30% representation, other sectors of society have been slow to follow, e.g. religion, the media, sport)

*women have little or no control over their own bodies and fertility (this despite the Constitutional provision and such progressive legislation as the Termination of Pregnancy Act) [Legislation such as the Sexual Offenses Law, Legalisation of Sex Work, Legislation against Trafficking in women and children has yet to be passed]

 

Figure 1: Comparative levels of fertility in Southern and East Africa3

6. Past developments of South Africa's fertility trends

South Africa's experience in the fertility transition is among the most advanced in sub-Saharan Africa. South Africa displays demographic regimes that are typical of both developed and developing worlds. These tend to be linked to socio-economic divisions along racial and urban-rural lines. Among all the four major racial groups in South Africa a decline of fertility has been observed from as early as the 1960s. The swiftest decline occurred among the coloureds, followed by Africans.

For South Africa as a whole, fertility was high and stable between 1950 and 1970, estimated at an average of 6 to 7 children per woman. It dropped to an average of 4 to 5 children per woman in the period 1980 to 1995.6 The current total fertility rate of South Africa stands at 2,9.7

Whites experienced a long and sustained fertility decline from the end of the 19th century until attaining below-replacement fertility by 1989, with a TFR of 1,9.8 Asian fertility also declined steadily, from a TFR of about 6 in the 1950s to 2,7 in the late 1980s. Coloured fertility declined remarkably rapidly from 6,5 in the late 1960s to about 3 by the late 1980s. African fertility is estimated to have decreased from a high of 6,8 to a low of about 3,9 between the mid-1950s and the early 1990s. Although it continues declining, African fertility is still substantially higher than that of the other racial groups. However despite this dramatic decline in fertility the majority of African population, especially women still lives in poverty. The Malthusian theory of rapid growth is tantamount to underdevelopment no longer holds, since experience has proved that with population decline, poverty still remains a factor. Therefore the complexity of the issue and not the..... needs to be analysed and understood.

In tracing past history of South African population, one gets the view that this was strongly shaped by Malthusian theory. To illustrate this history, the then apartheid government began to provide strong support for family planning in the 1960s. This support was driven by the fear that rapid population growth would undermine South African prosperity and economic development, but also by concern among white political leaders and administrators that the fast growing black population would overwhelm the much smaller number of whites. As early as 1963, the apartheid government provided substantial funding for private and public family planning services and furnished free contraceptives. In 1974, the South African government launched the well-funded National Family Planning Programme.

The results were impressive and unprecedented in sub-Saharan Africa. By 1983, over half the eligible women in the country were practicing contraception. Despite the aim to lower the black population the government at the same time was encouraging an increase in the white population through immigration. The programme consequently came under much pressure, both for its ideological focus and the inadequacy of its services. By the mid-1980s the programme's management had distanced itself from the demographic intent of the Population Development Programme (PDP). Instead, it promoted the programme's health benefits and started to integrate family planning into other primary health care services.

The introduction of the Population and Development Programme (PDP) in 1984 was aimed explicitly at lowering the national population growth. The argument at the time was that rapid population growth has negative impact on environment and that in fact the country does not have adequate natural resources such as water to sustain the population. Ironically, the Black population was either being denied access to well water-resourced arable land or was being removed and relocated to poor water-resourced land. Thus the minority population owned, or was systematically taking ownership of most of the well water-resourced land in the country. The PDP included interventions in other areas that have an impact on fertility levels, namely education, primary health care, economic development, human resource development, and housing. However, it did nothing to the economic upliftment of the Black population and address women empowerment among the Black females.

It must also be said, while it fell short of its original objectives, the programme substantially expanded family planning services. By the end of the decade about 58 percent of women ages 15-49 (including about half black married women) were using some form of contraceptive. Thus ironically, while South Africa's family planning program was conceived and implemented by a minority white government intent on slowing the growth of the majority black population and the black communities resisted this approach. It must however made be clear that many black women adopted family planning despite the political agenda of the programme .

Most of these women were the only breadwinners and in this sense they were forced to adopt contraceptives. This can be seen in the context that African women assumed management of their fertility because they found themselves increasingly in precarious circumstances. Many factors - cultural, political and social - converged to deprive African women of financial and familial security. These circumstances compelled them to curtail childbearing and to practice family planning, with or without the consent of their husbands or partners. The high use of contraceptive injection indicates that many women are not free to discuss reproductive issues, including contraceptive use, with their husbands or partners. This suggests that the reproductive rights of majority of South African women are still under siege.

Furthermore, many rural African women were without husbands for long periods, since the latter served as migrant labourers in cities. Their prolonged absence left the women to fend for themselves and their children. Many of these migrant husbands simply stopped sending money home or earned too little to be able to afford doing so. This, together with the landlessness and joblessness of the homeland system, forced many African women to make their own decisions about family maintenance and reproduction. The modern family planning programme introduced by the white apartheid regime in the early seventies, assured that their need for fertility control was met. Thus African women accepted family planning, even though their need for fertility control was forceably created by the very cultural, geographical, social and economic factors entrenched by apartheid.

7. Policy and Interventions

The South African Population Policy that was adopted by the 1994 democratic government has shifted from the reproductive and family planning methods. It places population within the development paradigm which was advocated by the ICPD in 1994. The focus is to fully integrate population concerns into all development strategies, planning, decision making and resource allocation, with the goal of meeting the needs and improving the quality of life of the present and future generations.

Focus is especially placed on the status of women, specifically African and Rural women, adolescent reproductive health and questions around poverty. The aim is to address these problems in an integrated manner.

7.1 Flagship programme for women and children under five

The Department of Social Development is concerned with the intersecting needs of women and children. In order to demonstrate its move to new priorities in developmental social welfare, a Flagship Programme entitled "Developmental Programmes for Unemployed Women with Children Under Five Years" has been launch. The idea is to develop and/or support developmental programmes that create self-reliance. Objectives include building women's capacity for economic independence and empowerment, as well as providing developmentally appropriate education for children aged 0-5 years old. Funding was made available for pilot programmes within each of the nine provinces that in nine provinces, 1448 women participated. In seven provinces the programme reached 1 323 children. The Flagship programme has also provided access to early childhood development (ECD) opportunities. The children are either placed in existing ECD centre or some of the women have been trained and they care for children at the project site.

Thus the main aim of the Flagship Programme is to reduce poverty through providing income-generating activities to women. The specific objectives are: to promote human capacity, ensure self-reliance and well-being among its target population, develop and support unemployed women and their children under five years and facilitate economic, educational and training opportunities for women and their children so that they can provide for the basic needs of their families, thereby breaking the cycle of vulnerability and poverty as well as dependence on the state.

Research Methodology: In order to obtain comparative baseline data so that the situation of women participating in the Flagship Project could be evaluated, three groups of women in three separate provinces were included in the survey, namely (i) active participants in the Flagship Project (eligible women between 15-49 years of age), (ii) non-active participants who were waiting for the gardening project and (iii) a general sample women. The baseline data originated mainly from two means of observation, namely (i) an analysis of the environment (environmental scan) and (ii) a personal interview survey of the socio-economic, demographic and health characteristics of the population (the household and women interview surveys). meet these criteria.

7.2 Reproductive Health

NAFCI

National Adolescent Friendly Clinic Initiative (NAFCI) is a five-year project started in September 1999 due to be completed in 2004. It is led by the Reproductive Health Research Unit (RHRU) of the University of the Witwatersrand, which is based at the Chris Hani/Baragwanath Hospital. The project is a comprehensive service performance and quality improvement accreditation programme. Its initiatives include:

Once a clinic participates in the project, certain processes and guidelines need to be followed in order for the clinic to be NAFCI accredited and classified as adolescent-friendly. Project activities are carried out by the NAFCI team and clinic health care providers.

The project is currently being run in four provinces at ten clinics, with the intention to expand the project to 50 sites in 2001. The ten pilot clinics are in the following provinces:

As an integral component of Love Life, NAFCI will contribute to Love Life's goal to effect positive behaviour change among young South Africans to reduce teenage pregnancy, sexually transmitted diseases and HIV/AIDS.

The main objective is to contribute to making health care facilities more accessible and acceptable to adolescents.

It also aims:

To promote an appropriate clinic environment for the provision of adolescent health services.

7.3 UNFPA/GOVERNMENT OF RSA Proposed programme

The goal of the proposed programme is to contribute to improvements in the quality of life of the South African people through reducing the prevalence of HIV/AIDS; improving reproductive health and respect for reproductive rights; enhancing gender equality and equity, particularly among youth; and achieving population trends commensurate with social and economic development.  Subprogrammes will focus on reproductive health, population and development strategies, and advocacy.  Gender concerns, HIV/AIDS prevention, capacity building, and information, education and communication (IEC) would be incorporated into each subprogramme. 

Reproductive health.  The major purpose of the reproductive health subprogramme is twofold: to contribute to increased utilization of integrated, quality sexual and reproductive health information and services and to induce positive attitudes, values and behaviours with gender-sensitive perspectives among youth.  The assistance will target achievement of: (a) increased access for men, women and young people to quality reproductive health services integrated with gender-sensitive and HIV/AIDS concerns; (b) strengthened capacity in and support for the implementation of culturally sensitive interventions for the prevention of gender-based violence and for the management and care of survivors of violence; and (c) strengthened capacity of governmental and non-governmental partners to manage and coordinate reproductive health and HIV/AIDS programmes.

In light of the high level of adolescent pregnancy and high prevalence rates and risks of transmission of STIs including HIV/AIDS, the major strategy is to play a leading role in the promotion of expanded quality reproductive health and preventive services geared particularly towards adolescents and youth.  In addition to supportive IEC methods to promote attitudinal and behavioural change, the subprogramme will promote dual contraception, the provision of adolescent- and youth-friendly sexual and reproductive health services, and voluntary counselling and testing for HIV/AIDS.

The subprogramme inputs will focus on delivery of comprehensive reproductive health services, technical assistance, training and capacity building to complement the Government's contribution of human resources, operation and maintenance of health facilities, and provision of equipment and reproductive health commodities.

The proposed programme will also support the system of notification of maternal deaths and assist in integrating the feedback from this and other related information systems into the planning and implementation of the reproductive health programme.  To address low condom use, activities in support of greater male involvement in reproductive health would be promoted and would involve community-based organizations, including those with predominantly male membership, in the delivery of community-based reproductive health information and services, including distribution of condoms and other contraceptives.  Considering the comparative advantages of NGOs in IEC and service delivery, a further strategy will be to support strengthening of NGO-Government collaboration at all levels.

7.4 Water management

South Africa's experiences and lessons learned in implementing population, environment and development policies has demonstrated that community based initiatives, which resonate with people's basic needs, can make a huge difference among poor communities. A community-based environmental and reproductive health programme in two rural districts was initiated in 1998 by the government, together with UNFPA, the Planned Parenthood Association of South Africa and the Working for Water Programme. What is notable about the programme is the overt linkage of population interventions to an environment and development programme with beneficial effects to the communities through the provision of clean water, job creation and promotion of reproductive health information and services, including HIV/AIDS. The project, which was undertaken to restore original water flows to rivers and streams, created many jobs, especially for women, and then became linked to the provision of project based reproductive health services.

7.5 Food Security

The Department of Health initiated the Integrated Nutritional Programme (INP) in 1995 to address and prevent malnutrition. A process of assessment, analysis and action (Triple A Cycle) is followed to assess the situation, analyse the causes of the problem and to implement services and interventions to address the problem. The mix of services and interventions depends on the findings of the assessment and analysis as well as the availability of resources. It usually combines direct and indirect nutrition interventions and includes service delivery as well as behaviour change aspects.

Examples of direct nutrition interventions include nutrition education and promotion; micronutrient supplementation; food fortification; and disease-specific nutrition counselling and support. Indirect nutrition interventions could include parasite control; steps to improve access to food; provision of health care services; and provision of clean safe water.

The Department of Health operates at national level with a Directorate for Nutrition and provincial level with 9 Sub-directorates/divisions. Structures for managing the INP at regional, district and community levels also exist and are supported by various task teams, and committees.

To effectively reduce malnutrition it is important to collaborate with sectors within the health department as well as other departments. The INP cooperates with a number or sectors which include the Departments of Education, Agriculture, Welfare and Public works; universities and technikons; research institutions; NGO's, CBO's, community project committees; professional associations, consumer organisations, industry and international agencies.

7.6 Status of women/Gender commission

This commission focuses on gender equality in South Africa as well as poverty amongst women in rural areas. HIV/AIDS is also a focus point. Government departments that collaborate with this commission on various projects is the debts of Social Development, Health, Education, Agriculture, Justice and Police services.

The Joint Monitoring Committee on the Improvement of the Quality of Life & Status of Women (JMCIQLSW) held hearings in October and November on "How best can South Africa address the impact of HIV/AIDS on women and girls?" The Committee's brief is to monitor Government's implementation of CEDAW and the BPFA in relation to improving the quality of life and status of women. The Committee is guided by the needs of the poorest women (the majority of whom are African women). The Committee's priority is to monitor how government is addressing the impact of poverty, HIV/AIDS and violence on women. The Beijing Platform of Action includes "the girl child". While women across race, class, religion and culture experience violence and HIV/AIDS, poor women are more vulnerable and have fewer options. This emerged in all three sets of hearings the Committee held: on Poverty; Violence, and, most recently, the HIV/AIDS hearings. The Committee's activity on these three priorities has encompassed hearings in Parliament; workshops in rural areas, provincial meetings and a workshop in Parliament of 200 women, most of whom came from rural areas.

7.7 Integrated plan of children Affected and Infected with AIDS

This is a joint project of the debts of Health, Social Development, Education and Agriculture. The aim is to make interventions around HIV/AIDS. The programme has four components namely:

Although the focus states only children it actually focuses on the most vulnerable sectors of society namely women, children and the aged. Life skills is focussing on sexuality in education as well as out of school youth.

7.8 HIV/AIDS CAPACITY DEVELOPMENT COURSE FOR GOVERNMENT PLANNERS.

In October 1998, President Thabo Mbeki launched the Partnership against AIDS challenging all sectors and all spheres of government to become involved. Local Government, being closest to the people, and responsible for the delivery of services, is ideally placed to respond to this challenge. In 1999, an HIV/AIDS Toolkit for Local Government was developed and piloted in KwaZulu-Natal. Since then, two major initiatives have emerged which will, in the future; collaborate to ensure that Local Government takes its rightful place as the Leaders in the Partnership Against AIDS. 1. In November 2000, the Chief Directorate Population and Development (CDP&) convened a meeting with university representatives to develop an HIV/AIDS curriculum for planners from all spheres of Government. The Chief Directorate Population and Development (CDP&D) collaborated with the UNFPA, the Department of Public Service and Administration, South African Management Institute (SAMDI) and leading HIV/Aids trainers to develop a strategy aimed at enhancing the skills of all spheres of government to more effectively plan for the impact that HIV/Aids will have on services in South Africa. The strategy aimed at implementing short course training programmes for government planners and policy researchers on the impact of HIV/Aids for the planning of government services and programmes. Due to the size of the government, and the limited capacity of individual institutions to implement such a programme across the whole of government, the CDP&D decided on an approach that will standardise the curriculum, but decentralise the training. Through this 50 short (one-week) courses were conducted in nine provinces in South Africa. for 1000 government officials during 2001. The content of the standard curriculum will be developed with three objectives in mind, i.e. Creating awareness of the fact that HIV/AIDS will impact on all sectoral and integrated planning; Equipping government planners with basic methodological skills with which to approach planning for the impact of HIV/Aids; Enabling government planners to further pursue sectoral specialisation of the rudimentary skills obtained at the workshop.

7.9 National Youth Commission

This programme is aimed at involving youth in the reconstruction and development of our country. Services of young people are employed in order to educate other young people about dangers of unprotected sex. A sub-programme the Young Positive Living Ambassadors is an HIV/AIDS programme aimed at employing the services of young people to educate other young people about the danger of unprotected sex, especially HIV/AIDS.

8. PARTNERSHIPS

The United Nations Population Fund (UNFPA) proposes to support a population programme over a five-year period starting in January 2002 to assist the Government of South Africa in achieving its population and development objectives. The proposed programme was jointly developed by the Government and UNFPA in collaboration with other relevant development partners and non-governmental organizations (NGOs).  This was achieved through a series of discussions and dialogues with officials of key national institutions, especially the Ministry of Social Development and the Ministry of Health, and through workshops with government, NGO and civil society stakeholders.

The proposed programme takes into account the Government's existing development programmes and their review.  These include the national population policy; the Government's growth, employment and redistribution (GEAR) programme; the South Africa population report for 2000; the health sector development programme; the forthcoming national strategic plan for HIV/AIDS and sexually transmitted infections (STIs); the Common Country Assessment (CCA) and the United Nations Development Assistance Framework (UNDAF) for 2002-2006. 

The proposed programme was developed within the framework of a human rights approach.  All activities under the proposed programme, as in all UNFPA-assisted activities, would be undertaken in accordance with the principles and objectives of the Programme of Action of the International Conference on Population and Development (ICPD), which was endorsed by the General Assembly through its resolution 49/128.

8.1 OTHER EXTERNAL ASSISTANCE

A number of national and international NGOs and multilateral and bilateral donor agencies provide assistance to population and reproductive health programmes in South Africa.  However, reliable data on the details are difficult to ascertain due to the weak coordinating and monitoring system and mechanisms for external development assistance. 

In the health sector, the European Union is the largest contributor providing approximately $28 million for the period 2000-2002.  The assistance is for the provision of primary health care, health policy development, and improved health-care financing.  The United States is the largest bilateral donor, contributing approximately $50 million (1995-2004) to the general health sector with $10 million specifically dedicated to prevention and control of HIV/AIDS and STIs.  The United Kingdom's total assistance of roughly $21 million (1994-2002) focuses on reproductive health, prevention and control of STIs including HIV/AIDS, and adolescent reproductive health services, funding for which was channelled through UNFPA.

Japan's assistance to the health sector amounts to approximately $33 million (1998-2002) to help strengthen health service delivery in three provinces.  Italy contributes about $3 million (1998-2003) to primary health care in Kwazulu Natal, improved data systems and health management in Gauteng, and child health support at the national level.  Belgium's support of about $3 million has been for strengthening the National Department of Health in the areas of STI prevention, control of tuberculosis, improved national health management, and research on reproductive health and screening for cervical cancer in Western Cape.  Sweden supports HIV/AIDS prevention and human rights activities.  Ireland is supporting health activities in Free State.  Canada has supported research on health care and HIV/AIDS.  The proposed programme will actively promote collaboration with these bilateral programmes where feasible.

World Health Organisation's programme for 2002-2003 will cover technical assistance; training of health workers in HIV/AIDS prevention; reproductive health service delivery; care and support for those who are HIV/AIDS infected and affected; anti-retroviral treatment, especially for prevention of mother-to-child transmission; and promotion of safe motherhood.  UNFPA collaborates with WHO in training health workers in reproductive health and HIV/AIDS prevention.  UNICEF's support will include such areas as  improved access to primary health care, prevention of HIV/AIDS, and improved care and support for those infected and affected by HIV/AIDS.

To the extent that the proposed UNFPA, WHO, UNICEF and UNDP programmes are all based on the same CCA and UNDAF, they have a common direction in focusing on the three most disadvantaged provinces and the three priority needs as identified by the Government.  In addition, UNFPA, UNICEF and UNDP are to jointly execute a United Nations Foundation programme on reduction of HIV/AIDS transmission among adolescent girls.  In this programme posal, UNDP will focus on job creation while UNICEF and UNFPA concentrate on promoting attitudinal and behavioural changes and care and support for the infected and affected.

A number of national and international NGOs support reproductive health programmes and activities in the country.  Most of them receive assistance from the Government and donor agencies, which will help to foster coordination between the proposed programme and the activities of NGOs in the area of reproductive health.  Considering the positive effects of NGO-Government partnership, UNFPA will further strengthen its collaboration with the NGOs.  In addition, UNFPA recognizes the huge untapped potential for programme support from the private (corporate) sector, especially considering the efforts made by some private sector organizations to provide HIV/AIDS and STI prevention and control measures for their staff.

9. Conclusion

The South African experience in fertility transition has been unique in sub-Saharan Africa, if not the world. Fertility has declined substantially during the apartheid era to a TFR of 2,9, which is unprecedented relative to the rest of Africa. The transition towards closing the gap between low fertility aspirations and small completed family sizes has moved much further in South Africa compared to the rest of sub-Saharan Africa. However, this occurred amidst great social upheaval of especially Africans, the impoverishment of millions, a large proportion of whom were African women and their children, stark inequalities and the systematic disempowerment of women.

An attempt was made to explain the reasons for this dramatic fertility decline despite high levels of poverty and low levels of development. The issues of high non-marital fertility in South Africa and high contraceptive use were discussed in order to better understand the singular manifestation of fertility decline in conditions of low status of women and abject poverty. We found evidence that various factors converged to create the situation where women had to accept virtually sole responsibility for childrearing without access to productive resources. Their response was to control their fertility, not as a result of educational and career aspirations or affluent lifestyles, but as a survival strategy. The reproductive and sexual rights of South Africa's disadvantaged women were constantly disregarded and abused, on the one hand because of the total breakdown in family life caused by influx control and the homeland system and on the other hand because of their low status and lack of development. Nevertheless, they accepted contraception as their way of exercising some control over their own bodies.

The basic difference between fertility patterns in South Africa and the rest of sub-Saharan Africa is not based on fertility being valued differently; fertility is still highly valued in South Africa. Rather, it was deprivation of access to land and the total breakdown of the traditional lifestyle, both socially and economically, that made fertility control a rational choice for South African women.

However, the high levels of unwanted and teenage pregnancies as well as the high unmet need for contraception are still of major concern. This shows clearly that women, especially Africans and coloureds, still lack control over their own reproductive choices and still experience emotional trauma with respect to fertility. They further lack the development opportunities to empower themselves in order to take full control over their reproductive lives, as propagated by the Programme of Action International Conference on Population and Development in Cairo, 1994.

While poverty, racial and gender inequality and fragmentation of society persist, we cannot pride ourselves as South Africans on our excellent gains in fertility decline. As long as South African women do not enjoy freedom to control their own bodies within supportive relationships with husbands or partners, population problems relating to fertility will remain a major national concern.

Specific focus needs to be put on empowerment programmes for teenagers as well as vulnerable African rural women in order for them to take control of their reproductive choices. The lack of male responsibility for childrearing that was emphasised as a crucial contributing factor to African women's need for fertility control, holds significant implications for reproductive health programmes and services. Essential interventions include the upliftment of the status of women through education and employment, radical changes in the social structures that influence female autonomy and the eradication of poverty.