LPPKN Situational Analysis

UNITED NATIONS POPULATION FUND, MALAYSIA
SITUATIONAL ANALYSIS ON FAMILY PLANNING AND

REPRODUCTIVE HEALTH EDUCATION IN MALAYSIA
AND OTHER SELECTED MUSLIM COUNTRIES
2020
© National Population and Family Development Board (NPFDB), 2020
All rights reserved. No part of any article, illustration and content of this book may be reproduced in any form whatsoever
and by any means whether electronic, photocopy, recording or otherwise without the permission of the National Population
and Family Development Board, Malaysia.
National Library of Malaysia

Cataloging-in-Publication NPFDB
Situational Analysis on Family Planning and Reproductive Health Education In Malaysia and Other Selected Muslim Countries
Part I : Needs Analysis on Family Planning Policy
Part II: Reproductive Health Education: Policy And Plan of Action
ISBN 978-967-2079-14-9
Published by:
Human Reproduction Division
National Population and Family Development Board
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FOREWORD
DIRECTOR GENERAL
Alhamdulillah, our gratitude to Allah SWT for His bounty
and guidance, the study on the Situational Analysis of
the Family Planning and Reproductive Health Education
of Malaysia and Other Muslim Countries have been
successfully published. This study is an initiative
by the Ministry of Women, Family and Community
Development (MWFCD) through the National
Populationand Family Development Board (NPFDB)
in collaboration with the United Nations Population
Fund (UNFPA), who has been a strategic partner of
NPFDB since the 1990s in the Sexual and Reproductive Health (SRH) programmes. This study
was conducted at the right time, where there are rapid changes in the population dynamics and
demographic trends together with the advancement in human capacity development and new
communication technologies. It is an effort that enables the nation to achieve its commitment locally
towards Malaysia’s Shared Prosperity Vision 2030 agenda and internationally, such as the ICPD Plan
of Action.
The report of this study proposes several strategies and improvements as a result of a gap analysis
with other Muslim countries that can help strengthen the strategy and implementation of the National
Sexual and Reproductive Health programmes to improve reproductive health indicators such as
Maternal Mortality Rate, Infant Mortality Rate and Age Specific Fertility Rate, as well as reducing
the number of cases of teenage pregnancy, abortion, sexual abuse and sexual crimes.
The highest appreciation goes to the members of the technical research committee from various
agencies, consultants and secretariat involved in ensuring the success of this study and materialising
this report.
Thank you.
TUAN HAJI ABDUL SHUKUR ABDULLAH

Director General,
National Population and Family Development Board, Malaysia (NPFDB)
4
FOREWORD
UNFPA
The subject of Sexual and Reproductive Health and
Rights (SRHR) features prominently in international
instruments that Malaysia has made commitments to in
particular the Programme of Action (PoA) of International
Conference on Population and Development (ICPD) and
the Sustainable Development Goals (SDG).
In Malaysia, Family Planning, since it was introduced in

1966, is provided as an integrated service by public and
private providers and by NGOs. Despite uninterrupted
services since 1966, Malaysia has attained only a modest CPR, and the unmet need of family planning
is still at an insufficient level to attain the goals of ICPD and SDGs. UNFPA commends Malaysia’s efforts
in having introduced in 2009, and continually strengthening SRHE, both in-school and out-of-school
setting; the National Policy and Plan of Action on Reproductive Health and Social Education, or
PEKERTI, coordinated by the National Population and Family Development Board (NPFDB).
It is therefore commendable that NPFDB has taken this initiative to review and update the policy for
both Family Planning Policy and SRHE. UNFPA values its partnership with NPFDB in supporting this
effort with a sense of conjoined duty towards a common goal. Recognising the strong influence of
religion and culture on SRHR and especially on family planning and SRHE, the review of these two (2)
policies include study of best practices in four (4) Sunni Muslim countries, as comparison for Malaysia –
Bangladesh, Egypt, Morocco and Turkey.
I take this opportunity to thank the UNU-IIGH, which conducted this multi-country studies to generate
evidence for both policies, which in turn will contribute immensely to the strengthening of family
planning and sexuality education in the country.
On behalf of UNFPA, I hope that this report will be instrumental in strengthening both Family Planning
services and comprehensive sexuality education in Malaysia through a well-informed evidence-based
policy and plan of action.
Thank you.
NAJIB M. ASSIFI
UNFPA Malaysia Representative A.I
5
RESEARCH TEAM
PROJECT DIRECTOR UNFPA TEAM
Hairil Fadzly Md. Akir Dato’ Dr. Narimah Awin
Jayamalar Samuel
PROJECT MANAGER
Dr. Hamizah Mohd Hassan CONSULTANT TEAM
Dr. Fatima Ghani,
NPFDB TEAM United Nations University-International Institute
Dr. Mohd Azizuddin Mohd Yussof for Global Health (UNU-IIGH)
Dr. Wan Hilya Munira Mustapha Intern: Yasmin Jasmy, UNU-IIGH
Noor Azlin Muhammad Sapri
Sofia Md. Yusop SECRETARIAT
Human Reproduction Division, NPFDB
ACKNOWLEDGEMENT
Highest appreciation to all Technical Working Committee Members from ministries and agencies as
stated below:
• National Population and Family Development Board (NPFDB)

• United Nations Population Fund (UNFPA), Malaysia
• Ministry of Women, Family and Community Development (MWFCD)
• Ministry of Health Malaysia (MoH)
• Ministry of Education Malaysia (MoE)
• Ministry of Higher Education Malaysia (MoHE)
• Ministry of Youth and Sports (KBS)
• Economic Planning Unit (EPU)
• Department of Islamic Development Malaysia (JAKIM)
• Federation of Reproductive Health of Malaysia (FRHAM)
• University of Malaya (UM)
• Kuala Lumpur Hospital (HKL)
• United Nations University-International Institute for Global Health (UNU-IIGH)
• UNFPA Asia and The Pacific Regional Office, Bangkok, Thailand
Thank you to all individuals involved in realizing the Study on Situational Analysis on Family Planning
and Reproductive Health Education in Malaysia and Other Selected Muslim Countries.
6
PART I: NEEDS ANALYSIS ON FAMILY PLANNING POLICY
7
8
NO TABLE OF CONTENTS PAGE
1. FOREWORD 4
2. RESEARCH TEAM 6
3. ACKNOWLEDGEMENT 6
4. GLOSSARY 10
5. LISTS OF FIGURES AND BOXES 12
6. LISTS OF TABLES 13
7. EXECUTIVE SUMMARY 14
8. INTRODUCTION 19
Background 19
Malaysia Family Planning Context 19
The Need to Develop a Family Planning Policy for Malaysia 20
9. CONCEPTUALISING FAMILY PLANNING 21

International Family Planning Comitment 21
10. METHODOLOGY 23
Ojectives of review 23
Selection of Comparative Muslim Countries 23
Data Collection 23
Guiding Frameworks for Developing a Family Planning Policy 24
11. FINDINGS 33
The Islamic Perspective of Family Planning 33
Family Planning Policies and Services Across The Islamic World 36
Contextual Situation Across Selected Countries 37
Family Planning Policy Environment Across Selected Countries 43
Country Comparison of Family Planning Policies, Programme and Indicators 58
12. DISCUSSION 63
Family Planning Best Practices 63
Family Planning Policies and Programme Across Selected Countries 64
Family Planning Service Delivery Across Selected Countries 65
Monitoring and Evaluation 67
Priorities for Family Planning in Malaysia 67
13. LIMITATION 69
14. CONCLUSION 69
15. RECOMMENDATION 71
16. ROADMAP FOR FORMULATING AND IMPLEMENTING A FAMILY PLANNING POLICY 74
17. APPENDIXES 80
9
GLOSSARY
ACRONYM EXPANDED NAME
ACCRH Advisory and Coordinating Committee for Reproductive Health

AFR Adolescent Fertility Rate
AIDS Acquired Immunodeficiency Syndrome
AMLAC Moroccan Association to combat Clandestine Abortion
ARROW Asian-Pacific Resource and Research Centre for Women
CEDAW Convention on the Elimination of All Forms of Discrimination Against Women
CIP Costed Implementation Plan
CPR Contraceptive Prevalence Rate
COVID-19 Coronavirus Disease-19
CRC Convention on The Rights of The Child
CRPD Convention on the Rights of Persons with Disabilities
CSE Comprehensive Sexuality Education
DHS Demographic Health Survey
EFPA The Egyptian Family Planning Association
EU European Union
FRHAM Federation of Reproductive Health Associations, Malaysia
FGM Female Genital Mutilation
FP Family Planning
GBV Gender-Based Violence
GP General Practitioner
HIPs High Impact Practices
HIV Human Immunodeficiency Virus
HPNSP Health, Population and Nutrition Sector Programme Plan
ICPD International Conference on Population and Development
ICPD PoA International Conference on Population and Development Programme of Action
IEC Information, Education and Communication
IUD Intrauterine Devices
LARC Long Acting Reversible Contraceptives
LPPKN Lembaga Penduduk dan Pembangunan Keluarga Negara
MCH Maternal and Child Health
MCH–FP Maternal and Child Health and Family Planning
mCPR Modern Contraceptive Prevalence Rate
M&E Monitoring and Evaluation
MMR Maternal Mortality Ratio
PM Permanent method
10
GLOSSARY
NIPORT National Institute of Population Research and Training

MWFCD Ministry of Women, Family and Community Development
MoH Ministry of Health
MoHP Ministry of Health and Population
NPFDB National Population and Family Development Board
NCIFP National Composite Index on Family Planning
NFPE National Family Planning Effort Index
NGO Non-governmental Organisation
NPC National Population Council
NPS National Population Strategy
PEKERTI Pendidikan Kesihatan Reproductive dan Sosial (Reproductive Health and Social Education)
PHC Primary Health Care
PoA Plan of Action
QOC Quality of Care
TFR Total Fertility Rate
TOP Termination of pregnancy
SDG Sustainable Development Goal
SRH Sexual and Reproductive Health
SRHE Sexual and Reproductive Health Education
SRHR Sexual and Reproductive Health Rights
STD Sexually Transmitted Diseases
STIs Sexually Transmitted Infections
SYPE Survey of Young People in Egypt
TWC Technical Working Committee
UHC Universal Health Coverage
UN United Nations
UNFPA United Nations Population Fund
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
WHO World Health Organization
11
LIST OF FIGURES
NO FIGURE PAGE
1. Figure 1: 22
Family Planning Benefits Shared Across Portfolios and Driving The SDG’s
2. Figure 2: 25
Socio-ecological Framework Depicting Determinants of Family Planning Use
LIST OF BOXES
NO BOX PAGE
1. Box 1: 31
WHO’s Short List of Reproductive Health Indicators For Global Monitoring
2. Box 2: 54
Evaluation of The Moroccan 2011-2020 National Reproductive Health Strategy
12
LIST OF TABLES
NO TABLE PAGE
1. Table 1: 26
Processes and Indicators- UNFPA’s General guidelines For National Family Planning
Policy Development
2. Table 2: 28
Summary Findings From Reviews Assessing Family Planning Policies and
Programmes
3. Table 3: 34
Religious Context Across Selected Countries
4. Table 4: 38
2019 Population Pyramids and Population Projections Across Examines Countries
5. Table 5: 58
Indexes For Comparing Family Planning Policies and Programme Across Countries
6. Table 6: 74
Roadmap For Developing A Comprehensive Family Planning Policy
7. Table 7: 80
Family Planning 2020’s Core Indicators 2019 To Monitor Progress Across
Selected Countries
8. Table 8: 83
Family Planning Environments Across Selected Countries
9. Table 9: 102
Family Planning Related Objectives and Recommendations From Malaysia’s
2010 Population Strategic Plan Study
10. Table 10: 104

Country Comparison Using The Family Planning Effort
11. Table 11: 107

Country Comparison Using The National Composite Index on Family Planning
13
EXECUTIVE SUMMARY
Family planning (FP) is a component of sexual and reproductive health (SRH)¹ and refers to the human
right of individuals to regulate the number and spacing of births. FP, particularly modern contraceptive
methods, is among the most health-promoting and cost-effective public health interventions, with
the potential to improve health outcomes by preventing unintended pregnancies as well as maternal
and infant morbidity and mortality. Some methods also prevent sexually transmitted infections (STIs),
including HIV/ AIDS. Increased contraceptive use is estimated to have prevented 40% of maternal
deaths in developing countries over the past 20 years². A further 30% could be prevented by
addressing the unmet need for contraception³ by removing legal, regulatory, and social barriers
to FP and SRH policy and programmes where appropriate⁴.
Several international frameworks, including the International Conference on Population and

Development Programme of Action (ICPD PoA), the Beijing Platform of Action, and the Sustainable
Development Goals (SDGs) Agenda reflect the international evidence-based consensus that universal
access to FP is a human right; central to gender equality and women’s empowerment, and a key
factor in reducing poverty and achieving the SDGs.
This desk review presents the latest evidence on best practices aligned with international FP
guidelines and compares FP policies and practices across selected Sunni Muslim countries: Turkey,
Egypt, Morocco, Bangladesh, and Malaysia. A combination of data collection methods was used,
including document review, a comparative analysis of FP environments across the selected countries,
and stakeholder consultations with the NPFDB, UNFPA, and Technical Working Committee (TWC). This
report provides important insights to inform Malaysia’s next steps regarding FP policy and programme.
¹ La’o Hamutuk (2018) Inclusive Family Planning takes more than words on paper
² UNFPA Choices not Chance, UNFPA Family Planning Strategy 2012-2020
³ Prof. John Cleland MA, Contraception and Health. The Lancet, Volume 380 Issue 9837, July 2012, pp.149-156.
⁴ UN Women (1995) The Beijing Declaration and Platform for Action, Fourth World Conference on Women
14
1. Summary of Results Across Selected Countries
Reproductive health is a critical public health issue, and the selected countries differ in their
commitments to SRH rights and FP principles, adaptations, implementation, and progress
measurement. The selected countries, particularly Malaysia, have made remarkable progress in
human and economic development. There are legal and policy frameworks for SRH matters, such as
the age of marriage, abortion, and gender-based violence (GBV).
Following international consensus, all selected countries except Malaysia consider FP a component
of a broader SRH plan, encompassing sexuality education (particularly for youth), prevention and
treatment of sexually transmitted diseases (STDs) and infections (STIs), including HIV/ AIDS; and
perinatal care⁵, rather than an isolated policy. This approach facilitates the linkages with SRH
rights and strengthens the policy or plan. There are notable policy and programme weaknesses
when measured against best practice, such as weak policies for vulnerable populations and exclusion
of men’s roles and responsibilities within the family unit.
The current national population direction varies across the countries; Malaysia, Turkey, and Morocco
earlier contraceptive programme reduced the Total Fertility Rate (TFR) to replacement rate by 2018
(2 births per couple) with populations projected to decrease. Their current population strategies are
pronatalist to prevent an economic slowing typical of developed countries, attributed to a shrinking
working-age population and an ageing population with a high dependency ratio. In contrast,
overpopulated Egypt and Bangladesh are still focusing on containing population growth, which places
pressure on their limited resources, commonly seen in developing countries.
The prioritisation of FP and SRH issues within the national agendas is influenced by the wider
socio-cultural contexts. Across examined countries, and particularly Malaysia, less controversial
SRH services such as perinatal care services seem more likely to get buy-in from key stakeholders,
compare with sensitive services such as safe abortion or GBV services, which require specific strategies
to transform socio-cultural norms, beliefs and behaviours⁶.
Despite significant progress made, FP implementation remains a challenge across the selected
countries. Religion remains a key influence on FP and SRH rights. Most Islamic scholars (particularly
in Egypt) permit FP practices as the Quran does not prohibit them.
⁵ La’o Hamutuk (2018) Inclusive Family Planning takes more than words on paper
⁶ Lim, SC. Yap, YC. Barmania, S. Govender, V. Danhoundo, G & Remme, M. (2020) Priority-setting to integrate sexual and reproductive health into universal health
coverage – The Case of Malaysia, Sexual and Reproductive Health Matters (accepted manuscript)
15
Spacing pregnancies improves the physical health of mothers while reducing the family’s economic
burden. However, uninformed scholars might view FP as restricting the Islamic world’s growth/ strength
(as in the case in Turkey or Bangladesh), highlighting the need to sensitise and engage religious
scholars in broader FP efforts to improve infant and maternal health⁷. Additionally, premarital
sexual relationships across the selected countries are forbidden by Islamic Law and unapproved
by society. These two (2) factors translate into limited FP/ SRH education and services for youth who
face the risk of abuse, STIs and unwanted pregnancies.
In Malaysia and Turkey, the low fertility rate combined with pronatalist policies is likely to present
challenges regarding access to — and use of — contraception for all populations, particularly for
young people⁸, many of whom are premarital sexually active.
Domestic politics across selected countries play a crucial role in determining the extent to which a
rights-based FP/ SRH framework is implemented⁹. Egypt has been particularly successful in engaging
religious leaders in FP campaigns — a critical factor for sensitising populations — with renowned
Islamic teaching centers issuing fatwas favoring modern contraception and increasing the
acceptability of birth control within Islam¹⁰. In contrast, Turkey’s conservative political climate
since 2010¹¹ has restricted FP services for women, impacting policymaking, implementation, and
civil society activities related to the promotion of rights-based FP/ SRH¹².
Rational utilisation of existing limited national resources is a significant challenge to improving

reproductive health across the countries. Following best practices and with international support,
Egypt and Bangladesh have developed FP strategies accompanied by Costed Implementation Plans
(CIPs) to ensure FP policies and programmes are fully funded and successfully implemented to
achieve the national FP goals.
⁷ Shaikh BT, Azmat SK, Mazhar A (2013) Family planning and contraception in Islamic countries: a critical review of the literature. J Pak Med Assoc 63:S67-72
⁸ UNFPA Choices not Chance, UNFPA Family Planning Strategy 2012-2020
⁹ Yilmaz V, Willis P (2020) Challenges to a Rights-Based Approach in Sexual Health Policy: A Comparative Study of Turkey and England. Societies 10:33.
https://doi.org/10.3390/soc10020033
¹⁰ Shaikh BT, Azmat SK, Mazhar A (2013) Family planning and contraception in Islamic countries: a critical review of the literature. J Pak Med Assoc 63:S67-72
¹¹ Yilmaz V, Willis P (2020) Challenges to a Rights-Based Approach in Sexual Health Policy: A Comparative Study of Turkey and England. Societies 10:33.
¹² MacFarlane KA, O’Neil ML, Tekdemir D, et al (2016) Politics, policies, pronatalism, and practice: availability and accessibility of abortion and reproductive health
services in Turkey. Reproductive Health Matters 24:62–70.
16
Examined countries should strengthen their monitoring and evaluation frameworks – crucial in
determining and documenting progress, assessing programme effectiveness, and making
recommendations for further improvements¹³. FP indicators should align with WHO’s reproductive
health indicators to enable global monitoring and international comparisons¹⁴. Each country
should also consider the contextual impact of COVID-19 developments on FP and SRH to design an
appropriate response¹⁵.
2. Specific Lessons For Malaysia
Considerable progress has taken place in Malaysia regarding FP. The 2019 Convention on the
Elimination of all Forms of Discrimination Against Women (CEDAW) review¹⁶ noted that Malaysian
women still experience availability, accessibility, and affordability barriers to high quality services.
A religious perspective is frequently adopted rather than a rights based SRH approach. This
perspective is typical for abortion and disproportionally affects vulnerable women and girls
(unmarried youth, refugees, indigenous, migrants, transgender and prisoners).
Malaysia had the lowest Contraceptive Prevalence Rate (CPR) and the highest unmet need across
the selected countries, despite a FP programme integrated into primary health care (PHC). The low
CPR and high unmet need are slowing the achievement of SDG target 3.7: ensuring universal access
to SRH services, including FP, information and education, and the integration of reproductive
health into national strategies and programmes by 2030. Addressing the paradoxical relationship
of low and stagnant CPR and declining TFR will require developing a strategic and integrated FP policy
as a priority within the national agenda. Special programmes for vulnerable populations (adolescents,
refugees and persons with disabilities) should be streamlined and strengthened¹⁷.
Malaysia acknowledges the importance of FP policies and programmes on fertility regulation as

reflected in the overall high scores for the 2014 Family Planning Effort Index (FPE)¹⁸ and the 2017
National Composite Index on Family Planning (NCIFP)¹⁹ compared to other countries.
¹³ The countries included Afghanistan, Egypt, Iraq, Jordan, Lebanon, Morocco, Oman, Qatar, Pakistan, Palestine, Saudi Arabia, Somalia, Sudan, Syrian Arab Republic,
Tunisia and Yemen. Six countries did not respond; Bahrain, Djibouti, Islamic Republic of Iran, Kuwait, Libya and the United Arab Emirates.
¹⁴ Measure Evaluation (2020) WHO’s short list of reproductive health indicators for global monitoring
¹⁵ Weinberger, M. Hayes, B. White, J. & Skibiak, J. (2020) Doing Things Differently: What It Would Take to Ensure Continued Access to Contraception During
COVID-19 Global Health: Science and Practice
¹⁶ Women’s Aid Organisation (2019) The Status of Women’s Human Rights: 24 Years of CEDAW in Malaysia.
¹⁷ Shrestha BD, Ali M, Mahaini R, Gholbzouri K (2019) A review of family planning policies and services in WHO Eastern Mediterranean Region Member States.
East Mediterr Health J 25:127–133.
¹⁸ FP2020 (2014) Family Planning Effort Index
¹⁹ FP2020 (2017) National Composite Index on Family Planning (NCIFP)
17
The high overall scores are due to the identified areas of strength which include: service provision for
improving Maternal and Child Health (MCH), service management and training of service providers,
and the collection of data for evaluation (Appendix 4). However, the Indexes scores and desk review
revealed the following critical gaps in FP policies and services that Malaysia should address as a priority:
1. Consider FP a component within a broader SRH plan under the existing National Population
Policy currently reviewed by NPFDB and the Policy Division with MWFCD rather than an isolated
policy.
2. Engage in participatory policy formulation by defining FP objectives over a 5-10 year period.
3. Ensure a rights-based FP policy and programmes by formulating operational policies to prevent
discrimination towards stigmatised groups providing equitable community-based distribution of
contraceptives for hard to reach areas.
4. Advocate FP for improving MCH across all future FP interventions among key stakeholders,
particularly community and religious leaders.
5. Strengthen FP service provision by engaging the private sector.
6. Implement Comprehensive Sexuality Education (CSE) to prevent unwanted pregnancies among
unmarried youth.
7. Address the needs of vulnerable populations, particularly the unmarried youth by increasing
the accessibility to emergency contraception and safe abortion and providing counselling and
contraceptive services for post-abortion women.
8. Strengthen the existing accountability mechanisms at national, subnational, and facility levels
to monitor FP information and service availability, accessibility, affordability, acceptability and
quality, particularly for vulnerable populations.
9. Increase the quality of FP services provided by improving and monitoring Indicators of Quality
of Care (QoC) collated by the public and private sector FP services, strengthening FP logistics and
supply system.
10. Review the FP related objectives and recommendations from Malaysia’s 2010 Population
Strategic Plan Study²⁰ (Appendix 3) as part of a roadmap leading to the formulation of a
comprehensive FP policy that addresses Malaysia’s FP gaps (Table 6).
11. Consider becoming an active member of – and regular contributor to – the Family Planning
2020 movement.
This desk review provides a comparison in FP policies and programmes across examined countries and
highlights the gaps when measured against international guidelines and best practices. A roadmap
informed by the lessons learned as well as FP guidelines and best practices is provided in Table 6 to
guide the formulation of Malaysia’s FP strategy and programmes.
²⁰ NPFDB (2010) Second Malaysian Population Strategic Plan Study 2010
18
INTRODUCTION
Background
Malaysia’s Family Planning Context
A 1968 report on the FP Programme in Malaysia articulates that on 1 June 1966 the Population and
Development Act 1966 became national law21. The Act established the NPFDB as an autonomous
statutory body with seven (7) objectives: (1) the formulation of policies and methods for the
promotion of FP knowledge and practice focusing on the health of mothers and children and the
welfare of the family, (2) the programming, coordinating and administering of national FP activities,
(3) responsibility for the training of all individuals involved in FP activities, (4) responsibility for
conducting research on FP medical and biological methods, (5) the promotion of studies and
research on the interrelationship across social, cultural, economic and population changes as well
as national fertility and maternity, (6) establishing evaluation mechanisms to periodically assess the
effectiveness of the programme and progress towards attaining the national objectives and (7)
employing officers and assistants as approved by the MWFCD for undertaking the functions and duties
of NPFDB. However, there is no national officially endorsed policy for FP in Malaysia22.
Although there is no officially endorsed FP policy, a 1996 operational policy statement guides the
implementation and coordination of the national FP programming in Malaysia as follows23:
1. FP services are conducted through a multi-sectoral approach between implementing agencies,

where NPFDB acts as coordinator.
2. FP service delivery is based on aspects of health and family’s health, and the practice is voluntary.
3. Contraceptive services will be provided through the cafeteria system and delivered by the medical
and support staff who are specially trained, with emphasis on medical services and follow-up support.
4. Provision of expertise and specialized counselling (genetic counselling, infertility treatment)
to improve the quality of FP services in the country.
5. FP Education/ Population integrated into the formal and non-formal education system.
6. Provision of FP in the Social Development Programme is intended to provide an opportunity
to improve the lives of family and socio-economic status of women. Improving the quality of
education and opportunities for women could indirectly lower the fertility rate.
21 Dr Ariffin M and Love T (1968) The Family Planning Program

22 Lembaga Penduduk dan Pembangunan Keluarga Negara and United Nations Population Fund (2020) Family Planning Policy Workshop Meeting Minutes
23 Lembaga Penduduk and Pembangunan Keluarga Negara website. Retrieved on 28 September 2020.
19
7. Provision of programmes and support activities aimed at improving quality of life. It covers
aspects of health, well-being and activities to promote and enhance the status of women.
8. Encourage medical, biological, socio-economic and cultural studies related to patterns associated
with maternity and fertility health on population growth and their impact on overall
socio-economic development.
The Need to Develop a Family Planning Policy for Malaysia
The need to review and update the 1966 Family Planning Policy statement is critical for aligning
Malaysia with the latest international FP frameworks and best practices.
To inform this review, NPFDB and the Secretariat to the Advisory and Coordinating Committee
for Reproductive Health (ACCRH) conducted the July 2020 Brainstorming Workshop with key
stakeholders24. The stakeholders included senior government officers from relevant ministries,
UNFPA and the principal researcher. The discussion covered whether to develop an SRH policy or
keep using the 1966 FP policy statement.
The TWC identified an opportunity to integrate a comprehensive FP policy within a broader SRH
plan under National Population Policy. This approach would first form part of Malaysia’s commitment
to meet international targets related to SRH indicators, including reducing the maternal and infant
mortality rate, addressing the unmet need for FP, and increasing the CPR. Secondly, an officially
endorsed policy would expedite the allocation of funds for the agreed programmes and activities.
Stakeholders also suggested that while awaiting the macro population policy review, Malaysia
addresses its commitment to SRH via relevant existing policies such as the Policy and Action plan
for National Reproductive Health and Social Education (Pelan Tindakan Pendidikan Kesihatan
Reproduktif dan Sosial, also referred as PEKERTI), the National Policy on Women and the National
Social Policy.
24 Lembaga Penduduk dan Pembangunan Keluarga Negara and United Nations Population Fund (2020) Family Planning Policy Workshop Meeting Minutes
20
CONCEPTUALISING FAMILY PLANNING
FP is among the most health-promoting and cost-effective public health interventions particularly a
modern contraceptive method and is a component of SRH including Sexual and Reproductive Health
Education (SRHE) particularly for youth, prevention and treatment of STIs (including HIV/ AIDS) and
perinatal care25.
International Family Planning Commitments
Many women’s limited power over their sexual and reproductive lives and lack of influence
in decision-making are social realities that adversely impact their health. National FP
programmes have made significant progress since the 1970s, shifting the focus from narrow
policies on population dynamics to a broad SRH and reproductive rights (SRHR) agenda
focusing on individual needs, choice and rights of people, particularly women and
adolescents. The approach further advocated for the respect of rights and choices, gender
equality, and women’s empowerment to ensure sustainable development. This agenda was
mobilised by two (2) major international forums: the ICPD and the Beijing Platform of Action.
The SDGs reiterate the agenda.
The ICPD PoA called for all people to have access to comprehensive reproductive health care,
including voluntary FP, safe pregnancy and childbirth services, and the prevention and
treatment of STIs.
The Beijing Declaration and the Platform for Action, adopted unanimously by 189 countries
at the Fourth World Conference on Women in 1995, is considered the most comprehensive
global policy framework for women’s rights26. It affirms the right of men and women to
be informed and to have access to safe, effective, affordable and acceptable methods of
FP of their choice for regulation of fertility which is not against the law, and the right of
access to appropriate health-care services that will enable women to go safely through
pregnancy and childbirth and provide couples with the best chance of having a healthy infant
Ensuring universal access to SRH and FP services by 2030 is one of the most cost-effective
SDG targets27, as investing in FP provides benefits across portfolios and drives the achievement
of the remaining SDGs (Figure 1).
25 La’o Hamutuk (2018) Inclusive Family Planning takes more than words on paper
26 UN Women (1995) The Beijing Declaration and Platform for Action, Fourth World Conference on Women
27 Health Policy Plus (2020) Family Planning-Sustainable Development Goals (FP-SDGs) Model
21
When couples exercise voluntary FP to space or limit pregnancies, it enables them to allocate limited
resources better, thereby increasing household wealth and improving nutrition and health. FP
contributes to gender equality by helping girls prevent early pregnancy, extend their education, and
make important life choices. It also enhances environmental sustainability and national and
international security by alleviating the pressures of rapid population growth and urbanisation
on economic and social resources28.
Figure 1: Family Planning Benefits Shared Across Portfolios and Driving The SDGs
Reduce
Hunger Empower
and Women
Poverty
Improve
Protect the Infant
Environment
FAMILY Health
PLANNING
Decrease Improve
the Spread Levels of
of HIV/AIDS Education
Improve
Maternal
Health
28 Health Policy Plus (2020) Family Planning-Sustainable Development Goals (FP-SDGs) Model
22
METHODOLOGY
Objectives of Review
The review aimed to achieve the following objectives:
1. Review FP strategies across selected Muslim countries with a Sunni majority to inform Malaysia’s
next steps;
2. Consider the existing international frameworks and guidelines and commitments related to FP
practices; and
3. Propose recommendations to develop an FP strategy that meets Malaysia’s multiracial and
multifaith society’s needs.
Selection of Comparative Muslim Countries
A list of countries that align with Malaysia’s Sunni faith was initially proposed, including Egypt,
Jordan, Bangladesh, Indonesia and Pakistan. The objective selection criteria were applied to the
proposed countries and compared contraceptive prevalence indicators, commitments to key international
conventions relevant to SRH rights and the existence of FP strategies. The latter included the level of
integration of FP policies into health care programmes, Islamic leaders support and committed public
budgets for FP programmes. The selection process identified Bangladesh and Egypt as the best
candidates for further country comparisons, with the best contraceptive prevalence progress
indicators. Morocco and Turkey as they are similar to Malaysia’s level of human and economic
development. Turkey, Morocco, Egypt, Bangladesh and Malaysia were the final agreed comparative
countries.
Data Collection
The desk review presents an evidence-based snapshot of the status of key variables supply, enabling
environment and demand29. Document review and stakeholder consultations were the data collection
methods used to meet the study objectives:
1. Document review, including the following activities:

i. Review of FP/ SRH international guidelines, peer-reviewed research publications on FP/
SRH best practice (past 5–10 years) and FP/ SRH issues for each selected country.
PubMed® and Google Scholar® were used as the main databases for collecting literature.
29 Engender Health (2011) The Supply–Enabling Environment–Demand (SEED)™ Assessment Guide for Family Planning Programming. New York.
23
ii. Review and compilation of relevant FP/ SRH country statistics from key sources.
These included the United Nations Development Programme, Human Development Index
ranking, Service Provision Assessments, Reports from Demographic and Health Surveys
(DHS), UNFPA, U.S. Agency for International Development (USAID) and WHO.
iii. Review of national policies and guidelines of the selected countries.

Country-specific national policies and guidelines and academic literature were reviewed.
Country-specific policies and guidelines tend to be published in the country’s official
language. Where English translation was not available, relevant documents and reports
published by reputable agencies were utilised. In the case of Morocco’s policy documents,
translation from French was required.
iv. Assessment of the current programmatic context in which the national Family Planning
programme operates.
Selected countries were examined based on the Family Planning Effort Index (FPE)30 estimating
the strength of national FP programmes and the National Composite Index on Family
Planning (NCIFP)31 , 32measuring the existence of FP policies and programme implementation.
2. Consultative meetings: The research proposal was presented to the TWC. A Workshop with key
stakeholders from related government and non-government agencies to inform the progress
of this desk review which was endorsed by the TWC.
Guiding Frameworks for Developing a Family Planning Policy
Three (3) frameworks were used to guide this review and comparative analysis: the socioecological
framework depicting levels of influence on FP usage; UNFPA’s Family Planning Strategy 2012-20 that
provides a set of guiding principles for FP efforts; and the FP policy development process, further
explained below.
1. Socio-ecological Framework
Figure 2 shows that comprehensive, multilevel strategies are required to facilitate an enabling
environment in which girls’ and women’s rights are promoted, reinforced practised33. Adopting a
socio-ecological framework commences with the individual and involves family and peers,
communities and the wider structural environment.
30 FP2020 (2014) Family Planning Effort Index

31 FP2020 (2017) National Composite Index on Family Planning (NCIFP)
32 Weinberger, M. & Ross, J. The National Composite Index for Family Planning (NCIFP), Avenir Health’s Track20 Project
33 Chandra-Mouli V, Plesons M, Hadi S, et al (2018) Building Support for Adolescent Sexuality and Reproductive Health Education and Responding to Resistance
in Conservative Contexts: Cases From Pakistan. Glob Health Sci Pract 6:128–136.
24
Figure 2: Socio-ecological Framework Depicting Determinants of Family Planning Use34
Socio-cultural
& Policy
Abortion
Environment Fertility
Laws Norms
Service
Religion Women’s
Accessibility Status
Distance & Costs
Transportation
Couple &
Quality Family Medical
of Care Barriers
Partner’s
(Dis)approval Communication
Access to Decision-
Resources making
Individual
Knowledge/ Awareness
Motivation
Self efficacy
Health concerns
Unmet need for FP refers to the gap between women’s reproductive desire to avoid pregnancy and
contraceptive behaviour. It is caused by a range of factors, including access. It is critical that policies
comprehensively address the unmet need for FP across different age, ethnic and religious demographics.
2. UNFPA Framework
Through Choices, not Chance, UNFPA’s Family Planning Strategy 2012-2035, UNFPA commits to
supporting countries accelerate universal access to rights-based FP services via voluntary FP
information, services, and supplies that allow individuals and couples to choose whether, when
and how many children they have.
34 Extracted from Cleland, J. Foster, G. Holley, C, Thompson, K (2014) Family Planning Topic Guide
35 UNFPA Choices not Chance, UNFPA Family Planning Strategy 2012-2020
25
The Strategy’s key indicators include the unmet need for FP, CPR, modern methods and the
percentage of countries with service delivery points offering at least three (3) modern methods
of contraception. Choices not Chance36 provides a set of guiding principles for FP efforts (Table 1).
UNFPA also provides general guidelines for national FP Policy development based on the 2030
Agenda for Sustainable Development. The guidelines include desk review, stakeholder consultations
and gap analysis, paying due consideration to contextual needs and practices. The health system
also requires up-to-date information about technological advances and risks37.
Other recommendations include supporting data collection for FP resource allocations, having a
structured communication plan, and engaging men and boys in planning and delivering interventions.
Table 1: Processes and Indicators - UNFPA’s General Guidelines for National Family Planning
Policy Development
Processes Key indicators / Considerations / Intervention areas
Background information Key data; indicators to be included:

• government spending on health; government spending on FP;
• market segmentation analysis – who provides the most
contraceptives – government or private sector? Preferred
methods of contraception; and
• unmet need – status; causes – where and why of inequities;
conduct a gap/ bottleneck analysis of the existing programme
and what needs to be done for improvement.
Obtain Consensus on data • meeting with the government to obtain agreement on national
data and indicators.
Convene subnational meetings with • meeting with the government to obtain agreement on national
ALL stakeholders* data and indicators.
Convene national level meetings • brainstorm on issues from subnational meetings and workshops;
with ALL stakeholders (including and
religious scholars and members from • building consensus on causes of inequities and non-utilization
faith-based organizations) of FP and how stakeholders can contribute to the programme.
Identify priorities and action points Policy level interventions and actions;
at different levels • actions at the service delivery level;
• actions at the provider level; and
• demand creation activities to improve utilization.

26
Processes Key indicators / Considerations / Intervention areas
At all levels emphasise on FP being FP as a fundamental human right committed to by the national
a Fundamental Human Right government under various international conventions and treaties.
Guiding principles will include human rights, reproductive rights
and gender equality.
Calculate resource requirements • human; financial; materials resource requirements for policy
implementation.
Identify targets, indicators and

timeline and also, how these will be
measured and monitored
* Stakeholder representatives from Ministries of health; education; planning; finance; youth affairs; United Nations (UN)
partners; other bilateral and multilateral agencies; International NGOs; private sector; manufacturers; representatives
from national medical, obstetrics and gynaecology, nursing and midwifery associations; academia and research scholars;
public health experts; demographers; experts on logistics and supply chain management; representatives from
religious and faith-based organizations; Civil Society Organisations and NGOs.
3. The Family Planning Policy Development Process
The FP policy development process requires several logical steps, starting with its design (which
should integrate a right-based approach and consider the characteristics of high impact policy and
programmes), and continuing with its implementation, financing, monitoring and evaluation and
potential adaptations to the changing environment (currently, the COVID pandemic).
i. Characteristics of high impact Family Planning policies and programmes
Several reviews of FP policies and programmes have been conducted, and results are
summarised in Table 2. The FP 2020 website provides resources to support countries as
they strive to strengthen their FP policies and programmes including a series of High
Impact Practices (HIPs) in FP.
27
Table 2: Summary Findings From Reviews Assessing Family Planning Policies and Programmes
Study type Findings
Family Planning Policies
A review of 23 case studies of earlier • There is marked consistency of features improving SRH
(1950-80) FP programmes³⁸ from a programme effectiveness for young people despite the wide
wide variety of social and economic variation in interventions reviewed.
environments. • Strong FP policies with broad popular consensus and consistent
programme leadership led to rapid success in contraceptive
adoption, with better results found in countries with higher
levels of education, higher status of women, and modern
transport and communications systems.
• Countries, where the FP programmes worked outside the MoH
network, had little access to facilities, personnel, or research and
evaluation resources.
Family Planning Programmes
2008 survey of key elements of • The 10 elements of FP programme success include:

successful FP programmes identified 1. Supportive Policies;
by 500 FP experts from 98 countries 2. Evidence-Based Programming;
based on experiences, best practices 3. Leadership and Management;
& evidence-based guidance³⁹. 4. Effective Communication;
5. Contraceptive Security;
6. Trained Staff;
7. Client-Centred Care;
8. Easy Access;
9. Affordable Services;
10. Integrated Services.
• Elements of Success in Family Planning Programming also
includes a useful checklist called “Assessing the Elements of
Success in Your Programme”.
38 Robinson, W. and Ross, J. (2007) The Global Family Planning Revolution. The World Bank
39 Richey, C & Salem, R. (2008) Elements of Success in Family Planning Programming
28
Study type Findings
Dramatic increases in contraceptive • Significant political commitment and policy changes beyond the
use in Ethiopia, Malawi, and health sector.
Rwanda⁴⁰ were underpinned by the • FP was explicitly recognised as a key contributing factor to
factors listed on the right. national priorities of gender, youth, women’s empowerment,
rural development and improved education.
• Programmes benefited from champions and collaboration with
domestic and international partners.
• Ministries of Health led FP Technical Working Groups as
collaborative forums with key partners.
• Innovative policies on task sharing expanded contraceptive
choice at the community level, and public-private partnerships
played were key in the success of Ethiopia and Rwanda’s FP
programmes.
A 2011 systematic review of 63 • Programmes using approaches to reaching women and couples
rigorous evaluations of FP with FP products and services, providing quality information and
interventions (1995-2008)⁴¹. • service delivery, addressing cultural norms and barriers to
contraceptive use, and seeking community support are generally
successful in increasing knowledge, attitudes, beliefs, and
discussions around FP as well as increasing contraceptive use
(particularly development and supply-side interventions).
This review provided the following recommendations:
i. Consider the differential impacts of programmes across
population subgroups, particularly those most in need of
services, such as high-risk subgroups, migrants, and the
urban poor. Information on the actual beneficiaries of
interventions would support policy that targets scarce
resources to those most in need.
ii. Understand the cultural backgrounds of the various
populations that are being studied, which helps in
explaining the different results in unmet need and where
these distinct populations are in terms of acceptance and
intentions to use FP methods, as well as looking at the
socio-demographic characteristics of beneficiaries.
40 USAID (2013) High Impact Practices in Family Planning (HIP). Family planning policy: Building the foundation for systems, services, and supplies.
41 Mwaikambo L, Speizer IS, Schurmann A, et al (2011) What works in family planning interventions: A systematic review of the evidence. Stud Fam Plann 42:67–82
29
Study type Findings
iii. Incorporates monitoring and evaluation (M&E) activities as

part of interventions planning to refine programmes and
share lessons learned widely. Rigorous impact evaluations
can attribute programme activities to changes in outcomes
of interest, which increase accountability, improve
programme decision making, and improve maternal and
infant health.
A 2009 systematic literature review • Most of the literature focused on individual elements of FP
identifying best practices in FP⁴². programmes, with service delivery models (particularly for
clinical services) being the most common. Very few documents
addressed FP programmes in their entirety, from a conceptual
and holistic perspective.
ii. Integrating a rights-based approach into Family Planning policy and programmes
FP 2020 identifies several rights and empowerment principles endorsed by the international
community, which should guide FP policy and programming to address the reproductive
health needs of men and women. Ensuring human rights principles within FP policies is critical
for sustainable, equitable and effective FP programmes that result in fewer unintended
pregnancies, fewer women and girls dying in pregnancy and childbirth, including from unsafe
abortions, and fewer infant deaths. Progressing this agenda requires establishing partnerships
across governments, civil society, the private sector and beneficiaries.
iii. Financing Family Planning policy and programmes
Domestic public financing is one of several HIPs identified by the Technical Advisory
Group (TAG) to the HIP Partnership43 based on the evidence of what works to support
countries in achieving high-quality, voluntary, equitable, and sustainable FP. The success
and sustainability of voluntary FP programmes rely on a robust national capacity to
implement and manage programmes and mobilise and spend the necessary financial
resources for FP commodities, service delivery, demand creation and training.
42 EngenderHealth (2011) The Supply–Enabling Environment–Demand (SEED)™ Assessment Guide for Family Planning Programming. New York.
43 FP2020 (2020) HIPs on Domestic Public Financing and Supply Chain Management
30
iv. Implementing effective Family Planning policies
Policy implementation may require creating an implementation plan, guidelines for providing
a service, and a budget or a budget line item to finance implementation. The budget line
item is required to ensure the policy is implemented as intended by policymakers and that
resources (financial, human and material) are available to accomplish the policy objective(s).
v. Monitoring and Evaluating Family Planning policies and programmes
WHO led an interagency technical process to reach consensus among international agencies on
a shortlist of 17 key indicators for national and global monitoring, international comparison,
and follow-up to the SRH conferences (Box 1).
Box 1: WHO’s short list of reproductive health indicators for global monitoring
1. Total Fertility Rate (TFR): Total number of children a woman would have by the end of her reproductive
period if she experienced the currently prevailing age-specific fertility rates throughout her childbearing life.
2. Contraceptive Prevalence Rate (CPR): Percent of women of reproductive age (15-49) who are using (or whose
partner is using) a contraceptive method at a particular point in time. The expert group working recommends
basing the calculation of contraceptive prevalence on all women of reproductive age, in contrast to the
convention used by the DHS and RHS to report it for married women only (or married and unmarried
women separately).
3. Maternal Mortality Ratio (MMR): Annual number of maternal deaths per 100,000 live births.
4. Antenatal Care Coverage: Percent of women attended at least once during pregnancy, by skilled health
personnel (excluding trained or untrained traditional birth attendants), for reasons relating to pregnancy.
5. Percent of Births Attended by Skilled Health Personnel (excluding trained or untrained traditional birth
attendants).
6. Availability of Basic Essential Obstetric Care: Number of facilities with functioning basic essential obstetric
care per 500,000 population.
7. Availability of Comprehensive Essential Obstetric Care: Number of facilities with functioning comprehensive
essential obstetric care per 500,000 population.
8. Perinatal Mortality Rate (PMR): Number of perinatal deaths per 1,000 total births.
9. Low Birth Weight Prevalence: Percent of live births that weigh less than 2,500g.
10. Positive Syphilis Serology Prevalence in Pregnant Women: % of pregnant women (15-24) attending
antenatal clinics, whose blood has been screened for syphilis, with positive serology for syphilis.
11. Prevalence of Anemia in Women: Percent of women of reproductive age (15-49) screened for hemoglobin
levels with levels 110g/l for pregnant women, and 120g/l for non-pregnant women.
12. Percent of Obstetric and Gynecological Admissions Owing to Abortion: Percent of all cases admitted to
service delivery points providing in-patient obstetric and gynecological services, which are due to abortion
(spontaneous and induced, but excluding planned termination of pregnancy).
31
13. Reported Prevalence of Women with FGC: %of women interviewed in a community survey reporting
having undergone FGC.
14. Prevalence of Infertility in Women: % of women of reproductive age (15-49) at risk of pregnancy (not
pregnant, sexually active, non-contracepting, and non-lactating) who report trying for a pregnancy for two
(2) years or more.
15. Reported Incidence of Urethritis in Men: % of men aged (15-49) interviewed in a community survey reporting
episode of urethritis in the last 12 months.
16. HIV Prevalence among Pregnant Women: %of pregnant women (15-24) attending antenatal clinics, whose
blood has been screened for HIV and who are sero-positive for HIV.
17. Knowledge of HIV-related Prevention Practices: % of all respondents who correctly identify all three (3)
major ways of preventing the sexual transmission of HIV and who reject three (3) major misconceptions
about HIV transmission or prevention.
Data Source(s): The DHS or other representative surveys of the intended population can provide certain indicators
(1, 2, 4, 5, 8, 11, 13, 14, 15, and 17). Other indicators (6, 7, 10, 12 and 16) require programme-level data: service
statistics, facility-based services, or laboratory results on clients. Whereas data are generally available for indicators
based on the DHS or RHS, data may be difficult to obtain for certain measures (e.g., percentage of OB-GYN admissions
owing to abortion). This set of indicators is not meant to serve as an index; rather, it draws attention to the key
measurable areas of RH.
32
FINDINGS
This section presents the findings from the literature review across selected countries, covering the
Islamic perspective on FP, the contextual differences regarding population and development trends
and SRH indicators (with a focus on Malaysia) and the various FP policy environments and their impact
on FP services. A final comparison of FP policies, programme and indicators is also provided using
the Family Planning Effort Index (FPE) and the National Composite Index on Family Planning (NCIFP),
extracted from the Track20 website44.
The Islamic Perspective of Family Planning
Most Islamic countries endorsed the ICPD PoA45 to enable individuals and couples to choose
the number and timing of their children. They also endorsed the SRH related SDGs46, albeit with
reservations in implementing the recommendations within Islamic Law. The ICPD PoA and other
agreements state that individual countries have the sovereign right to contextualise policies and
programmes to conform to customary laws, values and cultures.
Modern contraceptives, the restructuring of FP programmes and the international agreements on

birth spacing have all progressed FP globally. However, a 2013 review of FP across Islamic countries,
including Malaysia, Turkey, Morocco, Egypt and Bangladesh,47 noted significant social and economic
reasons to focus on FP in Muslim countries. Religion remains a central issue regarding FP and
contraception despite efforts from FP and birth spacing programmes and NGO advocacy. Most
Islamic scholars consider FP practices permissible, as neither the Quran nor the Prophet’s (PBUH)
tradition (Sunnah) prohibit birth control, spacing pregnancies, or limiting the number of children for
couples. Rather, Islam is considerate of FP as spacing pregnancies and reducing pregnancies increases
the mothers’ physical fitness and reduces the family’s economic burden. The 2013 review concluded
that governments should collaborate with key stakeholders in addressing gaps for advocacy
with religious scholars to support FP and birth spacing and improve infant and maternal health.
44 Family Planning 2020 Track20 website

46 UN General Assembly (2015) Transforming Our World: The 2030 Agenda for Sustainable Development
47 Shaikh BT, Azmat SK, Mazhar A (2013) Family planning and contraception in Islamic countries: a critical review of the literature. J Pak Med Assoc 63:S67-72
33
The Islamic laws regarding abortion make its legalisation a particularly controversial topic. Islam
generally considers abortion to be wrong due to the sanctity of life valued in the Quran. The holy text
notes that it is not permissible to abort a child because the parents fear they will be unable to
provide for him or her. Most Islamic scholars agree that abortion is permissible if the pregnancy would
endanger the mother’s life48.
1. Religious Context Across Selected Countries and Their Impact on Family Planning
A 2013 review of FP across Islamic countries49 provides insights into the religious context across
Malaysia, Turkey, Egypt, Morocco and Bangladesh (Table 3)
Table 3: Religious context across selected countries50
Country Religious context
Malaysia Malaysia had policies for balanced, equitable, and sustainable development prior to the
ICPD. Reproductive health services, including FP, are integrated with the public and private
health care system. The Malaysian Government engages in regular consultations on
programme design and implementation with a range of stakeholders, including advocacy
groups, the private sector, and community groups, including the clergy.
However, the 2019 Convention on the Elimination of all Forms of Discrimination Against
Women (CEDAW) review⁵¹ noted that Malaysian women still experience availability,
accessibility and affordability barriers to high-quality services. The services are often
provided from a religious perspective, rather than a right-based SRH approach, particularly
abortion. The approach is disproportionally affecting vulnerable women and girls
(unmarried youth, refugees, indigenous, migrants, transgender and prisoners).
Turkey The integration of religious leaders in reproductive health programmes and education on
FP issues was prioritised to attain desirable fertility rates. Family impositions and religious
barriers had been important reasons for the non-use of contraception in Turkey. FP
programmes' effectiveness was maximised with the involvement of husbands and religious
and other influential leaders in the community. Increases in educational and sociocultural
levels and the removal of religion-related misinterpretations have led to a significant
decline in the number of pregnancies, the number of children, and abortions over time.
48 Word News (2020) Morocco Liberalizes Abortion Laws, Amends Penal Code
50 Extracted from Shaikh BT, Azmat SK, Mazhar A (2013) Family planning and contraception in Islamic countries: a critical review of the literature. J Pak Med
Assoc 63:S67-72
51 Women’s Aid Organisation (2019) The Status of Women’s Human Rights: 24 Years of CEDAW in Malaysia.
34
Country Religious context
Egypt The country's most authoritative interpreter of Islamic law (the Grand Mufti) issued a
religious decree in the mid-1930s permitting contraception, thus allowing birth control
clinics in Egyptian cities. He declared that the earliest followers of the Prophet (PBUH)
practised contraception with the knowledge of the Prophet, who did not forbid it. In 1964,
Sheikh Hasan Ma'mun encouraged contraception based on the changing needs of the
Muslim people. Since 1980, religious leaders have played a significant role in the State
Information Service's public education efforts by speaking out on the acceptability of birth
control in the eyes of Islam. In the 1990s, the National Population Commission made
population issues part of the educational curriculum, including the religious education
curriculum.
Morocco Women’s low use of contraceptives was attributed to religious extremists' barriers who
misinterpret Islam regarding FP. However, the working-class community’s economic
conditions could not be ignored when looking at the complex decision-making process of
reproductive health practices. Clergymen were engaged in the national programme to help
achieve desired results.
Bangladesh Husbands' disapproval of FP is still a deterrent to women's regulation of fertility. This

phenomenon highlighted the structural influences that explain fertility regulation
behaviour. Myths, false beliefs, and rumours about the use of oral contraceptive pills are
prevalent in Bangladesh. A lack of consultation with qualified FP workers and the influence
of religious norms and folk stories are still key hindrances in the uptake of oral
contraceptive use. However, Bangladesh's government has actively engaged Islamic
scholars to advocate for MCH, including FP.
Malaysian Laws provide an exception to the prohibition of abortion in section 312 of the Penal Code
193652. The exception is that a medical practitioner can legally perform abortions if they consider
that the pregnancy’s continuation would pose a greater risk to the woman’s physical and/or
psychological health than termination of the pregnancy. Under Syariah Law (Fatwa issued by the 26th
Muzakarah of the National Fatwa Committee 1990), abortion is allowed if the fetus is under 120 days
of gestation and the mother’s life is under threat or if the fetus is abnormal. Girls under 18 years
require parental consent53. Malaysia provides all three (3) levels of prevention. The MoH released the
Guidelines for Termination of Pregnancy in 2012, which set out the standards for safe abortion
services54.
52 Laws of Malaysia, Penal Code Act 1936, revised by Penal Code 574, amended by Penal Code 1989 Penal Code Amendment A1471 2014, s312
http://www.agc.gov.my/agcportal/uploads/files/Publications/LOM/EN/Penal%20Code%20%5BAct%20574%5D2.pdf.
53 Hazariah AHS, Fallon D, Callery P (2020) An Overview of Adolescents Sexual and Reproductive Health Services Provision in Malaysia. Comprehensive Child
and Adolescent Nursing 1-17.
54 As advised by the MoH representative to the TWC.
35
In Turkey, the Population Planning Law 1983 legalises abortion up to 10 weeks’ gestation55. However,
there is political opposition to abortion, resulting in a lack of safe abortion services. In 2012, the
government unsuccessfully proposed restricting access to safe abortion services. Nevertheless,
women have reported difficulty accessing abortion services across Turkey since 201256. Public
health institutions provide only 20% of abortions and more than half in private practices or private
hospitals57.
Morocco’s Penal code was amended to legalise abortion in cases of incest, rape and fetal malformation,
and maternal health risks58. The Egyptian Penal Code of 1937 (sections 260-264) prohibits abortion
under all circumstances.
However, given the stigma associated with abortion, particularly in Muslim countries, many unmarried
girls and young women may terminate their pregnancies illegally, underestimating abortion rates
where they are collected and reported.
2. Women’s Need for Family Planning
UNFPA conducted a review of women’s need for FP in Arab countries59 (including Morocco and
Egypt) using national surveys of married women conducted by the Pan Arab Project for Family
Health and the Demographic and Health Surveys (DHS). The review noted that the expansion
of FP services in the Arab region has led to an increase in women’s contraceptive use. The review
noted that countries should reduce unmet need by addressing both the demand for and supply
of FP services. Governments and NGOs can help remove social and economic barriers to using FP,
expand coverage of FP services, and improve the quality of information and services.
Family Planning Policies and Services Across The Islamic World
Due to unprecedented population global growth, FP and contraception have become a significant
priority, particularly in Islamic countries with large populations. It is paramount that religious leaders,
scholars, think tanks and local clergymen disseminate the correct information and actively engage in
advocacy for the promotion of birth spacing for the improvement of MCH outcomes. Improving literacy
rates through investment in girls’ education is another proven strategy to improve reproductive
behaviours60.
55 Turkey (1983) Law No. 2827 of 1983 Population Planning Law [Turkey], 24 May,
56 MacFarlane KA, O’Neil ML, Tekdemir D, et al (2016) Politics, policies, pronatalism, and practice: availability and accessibility of abortion and reproductive health
57 Mihciokur S, Akin A, Dogan BG, & Ozvaris SB (2014) The unmet need for safe abortion in Turkey: a role for medical abortion and training of medical students,
Reproductive Health Matters, 22:sup44, 26-35
58 UNFPA (2016) Sexual and Reproductive Health Laws and Policies in Selected Arab Countries
59 UNFPA (2012) Women’s Need for Family Planning in Arab Countries
60 United Nations (2000) The millennium summit. New York
36
Integrating Sexual and Reproductive Health Services into Primary Health Care
Different approaches are used to integrate SRH services at the PHC level, aiming to provide
comprehensive services. A 2020 study assessed gaps in the delivery of SRH in PHC services in
11 Arab countries in 2017-18, identifying challenges and proposing action towards universal
health coverage61. Desk reviews using published programme reports and national statistics were
compiled from country reports to present a regional assessment, challenges and recommendations.
The assessment found that SRH services are partially integrated into PHC. The regional assessment
called for action at the policy, organisational, and operational levels, and prioritising services
guided by essential SRH care packages. Capacitating the PHC workforce in SRH services and the
adoption of the general practice model can ensure proper allocation of resources.
Contextual Situation Across Selected Countries
Socioeconomic determinants of health and human development underpin the SRH situation in any
country. This section uses selected human development indicators to examine the socioeconomic
status of each study country.
1. Demographic Trends and Human Development Indicators
The UN Global Human Development Indicators were used to compare the study countries
(Appendix 1)62. In 2018, Malaysia had the smallest population (32.7 million) across the selected
Muslim countries, followed by Morocco (36.0 million), Turkey (82.3 million), Egypt (98.4 million) and
Bangladesh (161.4 million). It also had the highest life expectancy (76 years). About 75% of Malaysia
and Turkey’s population live in cities, followed by Morocco, Egypt and Bangladesh. Malaysia had
the highest labour force participation across selected countries and the least percentage of youth
(15-24 years) out of school or employment63.
In 2018 the TFR was highest for Egypt (3.3 births per woman), followed by Morocco (2.4 births per
woman), Turkey (2.1 births per woman), and Malaysia and Bangladesh (both at 2.0 births per woman).
Malaysia and Turkey had introduced contraceptive programmes, which reduced the TFR to the
replacement rate in 2018. Bangladesh had also introduced contraceptive programmes and had
decreased the TFR to 2.0 births per woman, reflecting effective FP policy and programmes.
61 Kabakian-Khasholian T, Quezada-Yamamoto H, Ali A, et al (2020) Integration of sexual and reproductive health services in the provision of primary health care
in the Arab States: status and a way forward. Sex Reprod Health Matters 28:1773693
62 UN Human Development Programme (2020) Global Human Development Indicators.
63 The UN defines youth as those aged 15-24 years, while the Malaysian Youth Policy 2015 (Dasar Belia Malaysia) defines youth as those aged 15-30 years.
37
The population pyramids in Table 4 depict how the population structure is changing regarding fertility
rate, life expectancy, and dependency ratio projections of the selected countries. Population growth
is projected to decrease across all selected countries except Egypt, which is projected to increase.
Malaysia displays the typical shape of higher development with a contracting population pyramid,
declining birth rates, an ageing and shrinking population, longer life expectancy, and a projected
higher dependency ratio. The population strategy in Malaysia and Turkey shifted in recent years to
encourage a higher fertility rate, while Egypt and Bangladesh are focused on controlling population
growth.
Table 4: 2019 Population Pyramids and Population Projections Across Examines Countries64
Population Pyramids (%)

MALAYSIA Population Trends and Projections
0.0% 0.0%
0.0% 0.0% Contracting: declining birth
0.0% 0.0%
0.1%
0.3%
0.2%
0.4%
rates, longer life expectancy, Population
0.5%
0.9%
0.6%
1.0%
projected higher dependency
31,949,789
1.4%
1.9%
1.4%
1.8% ratio.
2.3% 2.2%
2.6% 2.5% Negative population growth
3.0% 2.8%
3.3% 3.0% with an ageing and shrinking
4.3% 3.9%
4.7% 4.4% population, typical shape of
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015
2020
2025
2030
2035
2040
2045
2050
2055
2060
2065
2070
2075
2080
2085
2090
2095
2100
4.7% 4.4%
4.6% 4.4% higher levels of development.
4.4% 4.1%
4.0% 3.8%
4.0% 3.8%
4.2% 4.0%
Overall projected to decrease

TURKEY Population Trends and Projections
0.0% 0.0%
0.0% 0.0% Contracting: declining birth
0.0% 0.1%
0.2% 0.3%
0.4% 0.6%
rate, lower death rate, slow Population
0.7%
1.0%
0.9%
1.3%
growth, consistent from age 83,429,607
1.4% 1.8%
1.8% 2.2% 16 below.
2.3% 2.5%
2.7% 2.9% Zero population growth,
3.1% 3.3%
3.5% 3.6% typical shape of higher levels of
3.8% 3.8%
3.9% 3.8% development.
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015
2020
2025
2030
2035
2040
2045
2050
2055
2060
2065
2070
2075
2080
2085
2090
2095
2100
3.9% 3.8%
4.1% 4.0%
4.2% 4.0%
4.1% 4.0%
4.2% 4.0%
4.1% 3.9%
64 Population Statistics (2020) Population Pyramid.net
38
EGYPT Population Trends and Projections
0.0% 0.0%
0.0%
0.0%
0.0%
0.0%
Expanding: high birth rate,
0.1%
0.2%
0.1%
0.3%
shorter life expectancy. Population
0.3%
0.7%
0.5%
0.9% Young and growing
1.0% 1.1%
1.4% 1.4% population, typical shape of 100,388,076
1.8% 1.8%
2.0% 2.1% developing nations, resulting
2.3% 2.4%
2.9% 2.9% in rapid population growth
3.5% 3.4%
4.0% 3.9%
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015
2020
2025
2030
2035
2040
2045
2050
2055
2060
2065
2070
2075
2080
2085
2090
2095
2100
4.1% 4.0%
4.3% 4.1%
4.4% 4.2%
4.8% 4.5%
6.1% 5.7%
6.6% 6.2%
Overall projected to increase

MOROCCO Population Trends and Projections
0.0% 0.0%
0.0% 0.0% Stable: moderate young
0.0% 0.0%
0.1%
0.3%
0.2%
0.5%
population, shorter life Population
0.6%
0.9%
0.8%
0.9%
expectancy resulting in 36,471,766
1.5% 1.5%
2.0% 2.1% slower population growth
2.4% 2.5%
2.5% 2.7%
2.6% 3.0%
3.0% 3.3%
3.5% 3.8%
3.8% 4.0%
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015
2020
2025
2030
2035
2040
2045
2050
2055
2060
2065
2070
2075
2080
2085
2090
2095
2100
4.2% 4.1%
4.1% 3.9%
4.1% 4.0%
4.3% 4.1%
4.8% 4.5%
4.7% 4.5%

BANGLADESH Population Trends and Projections
0.0% 0.0%
0.0% 0.0% Expanding: high birth rate,
0.0% 0.1%
0.1%
0.3%
0.2%
0.3%
shorter life expectancy but Population
163,046,173
0.5%
0.7%
0.5%
0.7%
with recent contracting
0.9%
1.4%
0.8%
1.2% trends attributed to
2.0% 1.9%
2.6% 2.4% antinatalist population policy,
2.8% 2.8%
3.3% 3.4% with declining birth rates,
3.8% 3.9%
4.1% 4.2% resulting in slower population
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015
2020
2025
2030
2035
2040
2045
2050
2055
2060
2065
2070
2075
2080
2085
2090
2095
2100
4.4% 4.4%
4.7% 4.6% growth
4.9% 4.7%
4.8% 4.6%
4.6% 4.4%
4.5% 4.3%
39
2. Sexual and Reproductive Health Indicators
There are well-known and commonly used SRH indicators to monitor progress in achieving the SDGs.
This section presents a selection to compare progress with MCH, FP, adolescent fertility rate and STIs,
particularly HIV/ AIDS.
i. Maternal and child health
Appendix 1 contains MCH indicators. Malaysia and Turkey have the highest antenatal care
coverage (97%) with at least one visit, followed by Egypt at 90%, Morocco at 77% and
Bangladesh at 64%. Malaysia has the highest percentage of births attended by skilled health
personnel at 99.5%, compared with 98% for Turkey, 92% for Egypt, 87% for Morocco
and 68% for Bangladesh. Malaysia also has the lowest infant mortality rate at 7.2 per
1,000 live births, compared with 10 for Turkey, 18.8 for Egypt, 20 for Morocco and 2.9
for Bangladesh, and the lowest under 5 mortality rate at 8.8 per 100,000 live births,
compared with 11.6 for Turkey, 22.1 for Egypt, 23.3 for Morocco and 32.4 for Bangladesh.
Turkey had the lowest MMR of 16 deaths per 100,000 live births, compared with 22 for
Malaysia, 33 for Egypt, 121 for Morocco and 176 for Bangladesh.
ii. Family planning
As discussed earlier in this section, Malaysia and Turkey have reduced the TFR to replacement
rate. Thus, in recent years, Malaysia and Turkey’s population strategy encourages a higher
fertility rate, whereas Egypt and Bangladesh focus on controlling population growth
(Appendix 1).
The prevalence of premarital sex is used as a proxy to measure shifts in adolescents’

attitudes toward sexual activity and inform the provision of SRH education and services.
The prevalence of premarital sex among Malaysians aged 12-24 years (measured by local
studies and national surveys during 2005-15) ranges from 1.3% to 12.6%65, depending
on the survey instruments, sample sizes, age groups, study periods and settings. Age at first
marriage is another proxy indicator for the initiation of sexual activity. The mean age at first
marriage among Malaysian men has increased from 25.6 in 1970 to 28.6 years in 2010. The
mean age has also increased for Malaysian women during the same period from 22.1 to
25.766. The increasing gap between the age of first sexual intercourse and the age of first
marriage suggests that many youths are sexually active before marriage.
and Adolescent Nursing 0:1–17.
66 Huang Soo Lee M, Lim SC (2012) Addressing the Unmet Need for Family Planning Among the Young People in Malaysia
40
Despite contraception services being available for all youth and women at government
clinics in Malaysia, the country had the lowest CPR (any method) at 52.2% in 2014
(stagnated since 1984) and modern methods at 34.3%67. Turkey’s contraceptive rale was
73.5%, Morocco 70.8%, Bangladesh 62.3% and Egypt at 58.5%68. Malaysia also had
the highest unmet need for FP69, at 19.6% in 201470, down from 25% in 200471.
Morocco’s unmet need was 13%, followed by Egypt at 12.6%, Bangladesh at 12% and
Turkey at 5.9%72. Malaysia’s low prevalence rate is partly attributed to the fact that SRH
services are not actively promoted. Malaysian adolescents may also be afraid to access the
services for fear of stigma and discrimination73.
The 2014 Malaysian Population and Family Survey (MPFS) revealed that 74.2% of ever-
married women aged 15-49 years have ever used FP methods74. It is important to consider
that FP indicators such as CPR75 and unmet need for contraception mainly capture
married women in predominantly Muslim countries; extramarital sexual activity is forbidden
for Muslims under Islamic Law. Since most unmarried women would want to avoid
pregnancy, the unmet need is likely to be underestimated76.
iii. Adolescent fertility rate and related issues
Out-of-wedlock birthing is strongly disapproved across Muslim countries. Malaysia had the
lowest adolescent fertility rate at 8.5 births per 1,000 women aged 15-19 years in 2018,
compared with 26.6 for Turkey, 53.8 for Egypt, 31 for Morocco and 82 for Bangladesh.
Adolescent pregnancy remains a significant health and socioeconomic concern in Malaysia,
with 13,383 teenage pregnancies recorded in 201577. Births among unmarried adolescents
are mostly unintended and lead to serious public health and socioeconomic consequences.
67 NPFDB (2016) Fifth Malaysian Population and Family Survey 2014 - Report on Key findings
6⁹ This refers to the number or percent of women currently married or in union who are fertile and desire to either terminate or postpone childbearing, but
who are not currently using a contraceptive method. The total number of women with an unmet need for family planning includes those with an unmet need for
limiting their number of children and those with an unmet need for spacing (who desire to postpone their next birth by a specified length of time).
Source: MEASURE Evaluation (2020) Unmet need for family planning
72 Unmet need: > 25% is considered very high; ≤ 5% is considered very low - Demand satisfied by modern methods: > 75% is considered high; ≤ 50 is
considered very low. Source: UN Population Division 2016 World Contraceptive Use (pg. 4)
73 ARROW (2018) Country Profile on Universal Access to Sexual and Reproductive Health: Malaysia
75 MEASURE Evaluation (2020) Contraceptive prevalence rate (CPR).
76 Najimudeen M, Sachchithanantham K (2014) An insight into low contraceptive prevalence in Malaysia and its probable consequences. Int J Reprod Contracept
Obstet Gynecol 2014; 3(3): 493-496 Volume No.3:493–496.
and Adolescent Nursing 0:1–17
41
Young unmarried pregnant women may spend their pregnancies in sheltered homes to hide
their pregnancies78. In 2018, 32,087 children aged 0-4 years were registered in childcare
centres overseen by the Malaysian Department of Social Welfare79. Unwanted teenage
pregnancy bears a heavy economic burden on Malaysia’s health andwelfare services.
Many unmarried girls and women may terminate their pregnancies. However, given the
sensitivities, abortion statistics are not reported. Research indicates that health care
professionals are not familiar with the abortion laws, leading to the misconception that
abortion is illegal and uniformed advice to continue with the pregnancy80. A 2007 study
noted that only 57% of the 120 doctors and nurses surveyed knew that abortion is legal in
certain circumstances and 38% of the doctors and nurses surveyed considered that
raped women should continue the pregnancy instead of terminating it, hig lighting
their conservative opinions regarding abortion81. Health care professionals should be
adequately briefed on the exceptions for abortion so they can provide accurate
information. Also, the collection and reporting of legal abortion statistics can inform
the proper allocation of resources to prevent further negative social consequences.
A tragic outcome resulting from the limited support provided to pregnant teenagers is the
common practice of baby dumping. Between 2010 and 2019, 1,010 babies were reported
by the Royal Malaysian Police as abandoned.
Limited SRH education, including contraceptive practices, are well-known barriers to

reducingthe adolescent fertility rate82.
iv. Sexuality transmissive infections, including HIV/ AIDS
Unprotected sexual intercourse is associated with a high risk of STIs, including HIV/ AIDS.
Malaysia had the highest HIV prevalence rate among adults aged 15-49 years (0.4 compared
with 0.1 for Egypt, Morocco and Bangladesh). This could be because Malaysia is actively
screening for HIV/AIDS cases. However, HIV/ AIDS transmission in Malaysia has shifted from
injecting drug users to sexual transmission in recent years⁸3.
78 Hazariah AHS, Fallon D, Callery P (2020) An Overview of Adolescents Sexual and Reproductive Health Services Provision in Malaysia. Comprehensive
Child and Adolescent Nursing 0:1–17.
79 Department of Statistics, Malaysia (2019) Statistics on Women empowerment in selected domains
80 Hazariah AHS, Fallon D, Callery P (2020) An Overview of Adolescents Sexual and Reproductive Health Services Provision in Malaysia. Comprehensive Child and
Adolescent Nursing 0:1–17.
81 Reproductive Rights Advocacy Alliance Malaysia (2007) Survey Findings of Knowledge and Attitudes of Doctors and Nurses on Abortion by the Reproductive
Rights Advocacy Alliance Malaysia (Unpublished)
82 Federation of Reproductive Health Associations, Malaysia (2010) ICPD+15 3rd Country Report of Malaysia: NGO Perspectives
83 Malaysian AIDS Council (2016) HIV Statistics.
42
The 2018 MoH Country Progress Report revealed that 43% of all new HIV infections in
Malaysia occurred among people aged 13-29 years (an increase from 40% in 2016),
with 90% of youth acquiring HIV infection through unsafe sex (an increase from 84%
in 2016)84. Out of the total reported HIV infections between 1986 and 2016, 11% were
females and 89% males, 69% were Malay, followed by 15% Chinese and 8% Indians85.
However, these indicators might underestimate the HIV incidence among youth, given the
low uptake of STI clinic services by adolescents86.
Family Planning Policy Environment Across Selected Countries
This section considers the contextual environment for FP policy, the FP policy direction and the programme
and services across the study countries. Appendix 2 contains a summary of the information.
Malaysia
1. Contextual Environment
Malaysia is transitioning from an upper-middle-income country to a higher-income country. The

population has grown slowly in recent years, from 31.7 million in 2016 to 32.7 million in 2020, of which
90.9% (29.7 million) are citizens, and 9.1% (3.0 million) are non-citizens87. Malaysia is projected to
be an ageing nation by 2030 with a decrease in annual population growth rate from 1.8% in 2010 to
1.5% in 2015 and projected to be 0.8% by 2040. In 2017, life expectancy at birth was 72.7 years for
males and 77.4 years for females88. Young people aged 10-24 years account for one-third of Malaysia’s
population89. Although Islam is Malaysia’s official religion, there are no restrictions on practising other
religions. Malaysia’s population is largely urban (76% living in urban areas), multi-ethnic (70% Malay;
23% Chinese; 7% Indian) and multi-faith (63% Islam, 19% Buddhism, 10% Christianity, 6%
Hinduism)90,91. Since independence in 1957, Malaysia has achieved impressive feats in human and
social development. Population health outcomes have improved remarkably (increased life
expectancy, decreased maternal and child mortality and communicable diseases). The improvement
in population health is primarily due to a universal, comprehensive and affordable health care system
funded through general taxation92.
84 Ministry of Health (2018) Malaysia, Malaysia 2018: Country Progress Report on HIV/AIDS
85 Malaysian AIDS Council (2020) Overview of the HIV & AIDS Epidemic in Malaysia
88 ARROW (2018) Comprehensive Sexuality Education for Malaysian Adolescents: How Far Have We Come?
91 Department of Statistics, Malaysia (2020) Population demographics
92 Ng CW, Mohd Hairi NN, Ng CJ, Kamarulzaman A (2014) Universal health coverage in Malaysia: issues and challenges
43
Malaysia established the 1966 Population and Family Development Act 35293, overseen by NPFDB, to
improve MCH and decelerate population growth rate from 3% in 1966 to 2% in 1985. FPs acceptance
was increased through its integration into the primary health system and linked with other
reproductive health efforts94.
The TFR in Malaysia has consistently declined for five decades; 4.8 births per woman in 1970 to 3.5 in
1990 to 2.0 in 2018. The 2018 TFR is below the replacement level of 2.1 births per woman95. Fertility
rates are lower among the sub-groups with higher CPR. These groups include non-Malays and those who
have completed higher education96. FP/SRH needs and preferences are diverse. Diversity should
be considered across religions and ethnicities when designing policies and programme to ensure
no-one is left behind.
2. Family Planning Policy Direction
Malaysia is committed to implementing the ICPD PoA and the Agenda 2030 for Sustainable
Development. Labour market policy and FP policy will need to address Malaysia’s ageing population
and the fertility decline to avoid the workforce’s inevitable contraction. Simultaneously, both policies
will need to sustain fertility at replacement level, while supporting couples to combine participation in
the labour market and their family building. The 2nd Malaysian Population Strategic Plan Study 201097,
provided objectives and recommendations, including addressing the fertility decline and long-term
population growth objectives, reproductive health, family and gender issues and demographic data
issues within a population strategic plan. Appendix 3 describes the objectives and recommendations.
Malaysia currently aims to reverse the fertility decline by exploring sub-fertility, pro-fertility
incentives and childcare options.
3. Family Planning Services
MoH mainly provides SRH information and services via clinics offering multidisciplinary services in
partnership with NPFDB and FRHAM, other agencies such as MoE. NGOs and the private sector also
provide these services. These health institutions have their own systems for procuring and delivering
SRH information and services98. The 2001 Adolescent Health Policy led to strengthened
adolescent SRH services.
93 Laws Of Malaysia (1966) Malaysia Population and Family Development Act 1966
94 UNFPA-ICOMP Regional Consultation (2010) Family Planning in Asia and the Pacific Addressing the Challenges - Malaysia
95 Department of Statistics, Malaysia (2020) Population demographics
96 Ahmad N, Peng T, Zaman K, et al (2010) Status of Family Planning in Malaysia
97 NPFDB (2010) Second Malaysian Population Strategic Plan Study 2010
44
Public health care facilities provided contraceptive and other SRH services to young people, regardless
of their marital status99. The 2009-12 PEKERTI Policy directed Malaysia’s efforts to increase access to
SRH information and services for young people, stressing positive values and responsible behaviour100.
In 1996, Malaysia started providing universal access to SRH services for all adolescents in primary,
secondary and tertiary health care facilities nationwide. In recent years, the MoH has led initiatives
to provide SRH services for both married and unmarried adolescents, as demonstrated by the MoH’s
2012 Guidelines for Managing Adolescents Sexual and Reproductive Health problems at Health Clinics.
SRH services in Malaysia have been made available to all groups, generally excluding abortion
services101 . Despite the availability of SRH services, unmet needs for contraceptive methods remain
high, as SRH services are not properly promoted, particularly among adolescents and young people.
Stigma and discrimination also play a role in the lack of access to SRH services by adolescents and
young people102. Unmet needs for SRH information, and access to contraceptives should be urgently
addressed to prevent further STIs and unintended pregnancies103. Health care providers should be
trained to deliver SRH information and services in a confidential, non-judgmental and non-
discriminatory manner.
Despite the MoH’s 2012 Guidelines for Termination of Pregnancy for hospitals, the lack of awareness
regarding abortion laws amongst Malaysia’s health care providers is likely to lead to illegal and
unsafe abortion practices.
SRH information and services often neglect older people. Malaysia’s life expectancy has increased
with health care advancement (74.7 years in 2016 to 76 years in 2018). The number of older
people (aged 60 years and above) is projected to increase from 10% in 2017 to 15% in 2030;
aged country status104. The rapid decline in fertility rates has accelerated the country’s ageing
process which will be reflected in increased morbidity and disability rates, some of which are
related to reproductive health such as menopause, andropause, breast, cervical and prostate cancer.
99 Ministry of Health Malaysia (2015) National Adolescent Health Plan of Action

102 ARROW (2018) Country Profile on Universal Access to Sexual and Reproductive Health: MalaysiaARROW
104 NPFDB (2018) Situational Analysis on Population and Family in Malaysia
45
The lack of public SRH programme and services for older persons might be due to various factors,
including limited research and data, inadequate training of health care providers, limited knowledge
of sexual matters among older people, limited knowledge of health issues and risk factors for
chronic diseases. Additional barriers could be cultural and religious beliefs, attitudes and stereotypes
of SRH and ageing, lack of information and awareness on SRH among the older population, physical or
psychological limitations caused by other health or economic problems and loss of independence.
The SRH needs of older people could be incorporated into SRH programme and services by building
service providers’ capacity in SRHE, monitoring and evaluation, and allocate financial resources and
personnel105 .
Turkey
Turkey was an upper-middle-income country of 82.3 million people in 2018. 75% of the population
lives in urban settings106. Turkey had accelerated development until the economic crisis of mid-
2018. Improved SRH, decreases in infant and maternal mortality and decreases in the TFR
(from 2.4 births per woman in 2003 to 2.1 in 2018) and the Adolescent Fertility Rate (AFR) (from
40 per 1,000 women aged 15-19 in 2003 to 26.6 in 2018) are attributed to the introduction of a
comprehensive FP programme and an increase in educational attainment. The FP programme
was introduced in 1965 and legalised contraceptives. The 1997 nationwide reform of compulsory
schooling age extended the basic educational requirement from 5 to 8 years (free of charge in public
schools) to align with the standards required to enter the European Union (EU)107.
The Turkish Government passed the first population planning law in the 1960s. In 1965, the General
Directorate of Maternal and Child Health and Family Planning (MCH–FP), an organ of the MoH, was
established. The MCH-FP is responsible for developing policies and strategies and evaluating MCH
and FP programme nationally108. The MoH, Universities and NGOs in Turkey have a long history of
collaboration with international agencies to provide reproductive health programme and services.
105 Huang Soo Lee M, Lim L (2016) Evidence based approach in addressing the sexual and reproductive health (SRH) of older persons in Malaysia
107 Güneş PM (2016) The Impact of Female Education on Teenage Fertility: Evidence from Turkey. The BE Journal of Economic Analysis & Policy 16:259–288.
https://doi.org/10.1515/bejeap-2015-0059
108 Ozvaris SB, Akin L, Akin A (2004) The Role and Influence of Stakeholders and Donors on Reproductive Health Services in Turkey. Reproductive Health Matters
12:116–127
46
During 1983-2000, Turkey successfully reduced its population growth rate as contraceptive use among
married couples rose to 71%, abortion incidence and maternal deaths from unsafe abortions declined,
as did the TFR109. Turkey has now shifted to a pronatalist policy to increase fertility to prevent an
economic slowdown attributed to an ageing population with a high dependency ratio and a shrinking
working-age population110.
The Women’s Health and Family Planning Advisory Board, established under MoH in 1993 and
chaired by MoH reports to Minister via the MCH–FP111. The Board meets twice a year to facilitate
inter-sectoral collaboration and monitor implementation of FP policies and programme. The Board
has successfully motivated all sectors to initiate new approaches and programme based on ICPD PoA
recommendations. The programme has included education for adolescents on SRH in schools and
education for soldiers to improve male involvement in fertility regulation and FP.
Successive Turkish governments enacted several laws in the second half of the last century to control
its population growth112. The first anti-natalist Population Planning Law, enacted in 1965,
improved women’s SRH by legalising the provision of contraception information and clinical
services. The 1983 Population Planning Law legalised induced abortions upon request for up
to 10 weeks’ gestation and allowed trained nurses and midwives to administer intrauterine
devices (IUDs). In 2012, Turkey adopted Law No. 6284 on the Prevention of Violence against
Women and the Protection of the Family. The government worked collaboratively with NGOs to
develop the 1995 Women’s Health and Family Planning Strategic Plan It focused on strengthening
inter-sectoral collaboration and the SRH components of PHC units to reduce regional differences
in health indicators, improve services quality, and involve NGOs. The SRH and FP services are
co-financed; however, the budget is limited. The MCH-FP pays for FP commodities (contraceptives,
equipment and educational materials), while MoH pays for personnel, maintenance and clinic
buildings.
Turkey issued a National Strategic Action Plan for SRH 2005-2015, which incorporated a rights-based
approach113. However, this approach came to a halt in 2010 when sexual health policy became more
conservative and shifted away from the previous commitment to a rights-based approach.
109 Ozvaris SB, Akin L, Akin A (2004) The Role and Influence of Stakeholders and Donors on Reproductive Health Services in Turkey. Reproductive Health
Matters 12:116–127
110 Yüceşahin, M. & Adalı, Tuğba & Türkyılmaz, Ahmet. (2016). Population Policies in Turkey and Demographic Changes on a Social Map.
111 European Committee of the Regions (2020) Turkey Public Health
112
113 Yilmaz V, Willis P (2020) Challenges to a Rights-Based Approach in Sexual Health Policy: A Comparative Study of Turkey and England. Societies 10:33.
47
While Turkey has made marked progress in FP to date114, access to SRH services has become
more limited in the last five years due to the conservative political environment. Since 2007 the
government’s pronatalist population plan incorporated into the most recent Four-Year Development
Plan115 encourages women to bear a minimum of three (3) children.
The main weakness of the MoH Strategic Plan is the absence of promotional SRHR services (including
gender issues) for young people116. The 2011 health structural reform shifted SRH services delivery
to family physicians, many of whom were not capacitated to deliver these. This led to implementation
barriers regarding the provision of commodities, STIs management, volunteer counselling and HIV
testing. While HIV prevalence is decreasing (0.3% in 2011), Turkey lacks epidemiological data on
key populations117.
Turkey FP related challenges118 related to gender inequality and include early marriage and GBV.
Approximately 15% of girls are married before the minimum legal age of 18119, affecting adolescent
SRH with a higher risk of obstetric complications. Data reveals that 35% of partnered women aged
≥ 15 years experienced sexual or physical violence from an intimate partner in 2017120.
Perinatal mortality rate remains high at 42 per 1,000 total births, indicating a need to improve maternal
health. There are marked differences in regional and rural/urban indicators attributed to gender
inequalities in educational levels and access to health care services. PHC services, including
reproductive health and FP, are limited in disadvantaged neighbourhoods. Abortion has been legal
and safe in Turkey since 1983, but the unmet need for safe abortion services remains high due to
political opposition. Only 20% of abortions have been provided by public health institutions and
more than half in private practices or private hospitals121. Thus, advocacy to prioritise reproductive
health services, and abortion care in particular, in the public health system is needed122.
114 Benezra B (2014) The Institutional History of Family Planning in Turkey. Contemporary Turkey at a Glance
116 UNPFA (2019) 2016-2019 UNFPA Country Programme Evaluation Turkey
12:116–127
120 Global Burden of Disease Collaborative Network (2017) Global Burden of Disease Study 2016 (GBD 2016) Health-related Sustainable Development Goals
(SDG) Indicators 1990-2030. Seattle, United States: Institute for Health Metrics and Evaluation (IHME), quote in (2016) Goal 5: Gender Equality - SDG Tracker.
In: Our World in Data.
121 Mihciokur S, Akin A, Dogan BG, & Ozvaris SB (2014) The unmet need for safe abortion in Turkey: a role for medical abortion and training of medical students,
Reproductive Health Matters, 22:sup44, 26-35
122 MacFarlane KA, O’Neil ML, Tekdemir D, et al (2016) Politics, policies, pronatalism, and practice: availability and accessibility of abortion and reproductive
health services in Turkey. Reproductive Health Matters 24:62–70.
48
Egypt
Egypt is a low-middle-income country with a population of 98.4 million people. Given the pressure
of overpopulation on limited food and water resources and agricultural land, SRH is a priority for
the Egyptian Government. Fertility levels decreased to 3.3 births per woman in 2018, and the AFR
was 53.8 per 1,000 births in women aged 15-19 years123.
Egypt has achieved remarkable progress regarding its national health indicators over the past decades.
Availability of basic health services is almost universal, and 95% of the population is now living
within 5kms of PHC centres. The Egypt Demographic Household Survey revealed improvements
in several key reproductive health indicators in the past 20 years, including reductions in maternal,
infant and child mortality due to increased coverage of maternal health services and perinatal
care (90% of mothers received antenatal care from a trained provider).
However, there are significant regional disparities in access to and provision of adequate FP services.
Poverty and rural settings are associated with high fertility and low contraceptive prevalence124.
Rural Upper Egypt is particularly disadvantaged regarding maternity care, with 57% antenatal
coverage, compared with 80% coverage among urban births125. Social, cultural, and religious norms
in Egypt have sometimes caused FP to be stigmatised.
A historical analysis of Egypt’s Population Policies noted that Egypt has a comprehensive population
policy since 1975 with clearly defined dimensions including population growth, distribution and
characteristics, and wide differentials between geographic regions or groups126. Significant progress
has been achieved in FP from the 1980s, with donor resources benefitting programme at all levels.
Progress slowed in the late 90s with reduced donor resources, which were not matched by
government resources. High-level political support has varied over time, affecting the level of
performance and the national programme’s support.
123 UNFPA (2020) Egypt Family Planning.

124 UNFPA Country programme document for Egypt (2018–2022).
125 UNFPA Egypt (2020) Sexual and reproductive health in Egypt
126 Hussein A. Egypt’s Population Policies And Organizational Framework UNFPA
49
The 2002-17 National Population Strategy (NPS) contained quantitative goals to reduce fertility to
replacement level and increase contraceptive utilization. The goals were to change the culture and
reproductive behaviour to reduce family size to two (2) children per family. These goals were also
clearly stated in the Population and FP Strategy 2007-12127. While the role of education is emphasised
in both strategies, full implementation is yet to occur128.
The 2015-30 NPS contains education goals directed at youth and those of reproductive age. The
education topics include FP methods, the value of smaller family size, SRH and GBV. The intention
is to target groups with high fertility and those living in poverty. The education programme will
be delivered via NGO door-to-door visits, training religious and community leaders (Muslim,
Christian) on FP and via sports festivals129. Several NGOs in Egypt have pioneered the development
of youth SRH programmes, although very few have been scaled up130.
The Egyptian Penal Code of 1937 (sections 260-264) prohibits abortion under all circumstances.
Existing legal, political and institutional frameworks for adolescents SRH rights do not guarantee
access to accurate SRH information or education131.
Despite Egypt’s strategic efforts to reduce population growth rates, a 2019 review of the NPS
2015-20 by the National Population Council (NPC) and UNFPA132 found significant challenges
hampering this effort. These include limited financial resources, varying levels of political support,
limited role of regional councils on population, weak follow-up and coordination mechanisms
and low participation from non-governmental organizations.
The Arab Republic of Egypt United Nations Partnership Development Framework (2018–2022)
United for a Sustainable Future supports Egypt’s government scaling up FP programme to meet
population goals133. Assistance from the European Union (EU) and UNFPA through the EU support
to Egypt’s NPS 2018 has the following objectives134:
i. FP services including contraceptive commodities scaled-up and more accessible (supply-side);

ii. Youth and population in reproductive age educated on FP, public awareness on the value of
smaller family size raised (demand-side); and
127 Nagi M (2017) Islam, Sexualities and Education. In: Daun H, Arjmand R (eds) Handbook of Islamic Education. Springer International Publishing, Cham, pp 1–26
129 UNFPA (2020) Egypt National Population Strategy 2015-30 progress review - Year 2
130 Wahba M, Roudi-Fahimi F (2012) Policy Brief: The Need for Reproductive Health Education in Schools in Egypt. Population Reference Bureau
131 Roushdy N (2013) Sexuality Education in Egypt: A Needs Assessment for a Comprehensive Program for Youth
132 NPC, Embassy of Switzerland in Egypt, and UNFPA (2019) Review of the Executive Plan 2015–2020 In the Context of the National Population and Development
Strategy 2015–2020
133 Arab Republic of Egypt United Nations Partnership Development Framework 2018 to 2022 United for a Sustainable Future
134 European Union, Egypt Ministry of Health and Population and UNFPA (2019) EU Support to Egypt’s National Population Strategy
50
iii. Institutional capacities for monitoring and coordination of the implementation of the NPS
strengthened (population governance).
The collaboration between the EU and the Government of Egypt initiated the development of a
Family Planning National Costed Implementation Plan 2019-23. The Plan is a multi-year actionable
roadmap designed to help the government achieve its FP goals and to ensure integration of services
and efforts, including public and private sectors, media institutions and NGOs135.
The Egyptian Family Planning Association (EFPA) is a lead Egyptian government partner in the National
Population Commission’s ongoing initiative to increase contraceptive prevalence. EFPA provides
information, education and communication (IEC) programme for the general public, many of which
run on a peer-to-peer basis, particularly amongst young people. Emergency intervention to prevent
reported early marriage cases is a key priority136.
A 2013 Egyptian study assessing youth-friendly clinics noted an improvement in the overall
environment for SRH education and service provision in recent years. Pilot government and non-
government youth-friendly clinics were established. However, their coverage and use remain limited,
with most beneficiaries being married women, highlighting the need to address cultural and religious
sensitivities. Government commitment is required to scale up pilot clinics into a national programme
to improve youth’s welfare137.
In 2018, the Government of Egypt pledged to reduce unmet need for FP from 12.6% in 2014 to
10.6% by 2020, the 12-month discontinuation rate from 29% in 2014 to 24% by 2020 and increase
the prevalence rate of all contraceptive methods used among married women (CPR) from 58.5%
in 2014 to 62.8% by 2020138. The Government is integrating FP into all PHC units and government
hospitals to facilitate universal coverage. FP methods and services are offered at low prices and also
free of charge in poor villages and mobile clinics139.
The FP programme of Egypt is noteworthy because it involves religious leaders in the FP campaigns. As
a consequence, contraceptives are available in Egypt in all government PHC facilities140.
136 IPPF (2016) Egyptian Family Planning Association
138 FP2020 (2018) Egypt FP2020 Commitment Self-Reporting Questionnaire 2018
139 FP2020 (2018) Egypt FP2020 Commitment Self-Reporting Questionnaire 2018
51
Under the National Population Strategy, launched in 2017, the Two (2) is Enough inter-
ministerial programme is implemented in partnership with local NGOs141. The programme includes
workshops, conferences, and door-to-door activities to distribute birth control methods to
the targeted 1.3 million mothers aged < 35 years to encourage them to have two (2) children
at most. These mothers are beneficiaries of an income support programme in 2,257 villages
within 119 departments in 10 disadvantaged directorates with the highest fertility.
In 2018, the Ministry of Health and Population (MoHP) launched a new FP programme in Egypt
in cooperation with USAID to respond to Egypt’s rapid population growth. The programme aims
to improve citizens’ health behaviour and support the quality of FP services and reproductive
health. Activities will help increase demand for FP services and enhance the quality of services, aiming
to improve contraceptive use and reduce fertility over time.
Morocco
Morocco is a low-middle income country of 36 million people (2018). During the last decades,
Morocco has made remarkable progress in reproductive health by increasing access to contraceptives
and reducing TFR and infant mortality. However, the reductions are insufficient compared to other
developing countries with a similar level of economic development142.
The age structure is changing, and the country is experiencing a transition at different levels
(demographic, geographic, economic, political, and epidemiological). Morocco has large disparities
in access to health and social services between urban and rural areas143. The country has
experienced a consistent decrease in TFR (2.4 births per woman in 2018) and teenage pregnancy
(5.5% of the female adolescent population in 2018), and adolescents are considered a
vulnerable population.
Morocco’s Penal code was amended to legalise abortion in cases of incest, rape and fetal
malformation, as well as in case of maternal health risks144. Previously, Article 453 of the
Penal Code mandated that abortion was only permissible if the health of the mother was in
danger145. Nevertheless, substantial legal and gender discrimination persists.
141 Wahish, N (2018) Family planning in Egypt: The ‘Two is enough’ project
142 Abdesslam B (2011) Social determinants of reproductive health in Morocco. African Journal of Reproductive Health 15
143 Abdesslam B (2011) Social determinants of reproductive health in Morocco. African Journal of Reproductive Health 15
145 Word News (2020) Morocco Liberalizes Abortion Laws, Amends Penal Code
52
FP commitments in Morocco guarantee the rights to reproductive health, to decide the number
and spacing of children, to consent to marriage, to be free from sexual and GBV and be equal in
marriage146. Morocco’s 2011-20 National Reproductive Health Strategy goals included: improving
institutional coordination, establishing a central authority regarding SRH, improving access of
target populations to SRH services (including adolescents), integrating an SRH monitoring and
evaluation system, strengthening SRH communication and partnerships and conducting SRH research.
The areas of focus included: FP, STIs, improve adolescent’s knowledge of SRH and contraception,
address violence on women and children, and provide perinatal care to reduce maternal and child
mortality as well as prevent uterine and breast cancer. Secondary objectives included: promotion
of pre-marriage consultations, infertility treatment awareness and improvement and health issues
related to menopause. The Moroccan Parliament introduced a 30% gender quota in the 2011
budget for the implementation of the 2011-20 National Reproductive Health Strategy under Law 130.
The 2020-25 National Reproductive Health Strategy refers to UNFPA’s framework for adolescent SRH
for integrating SRH information and services and is yet to be implemented147. It has several strategic
principles: institutional coordination and evaluation, increasing access to SRH services for targeted
populations, integrate a monitoring and evaluation system and strengthening SRH partnerships and
research.
The focused areas include adolescents’ SRH, physical and mental health Including STIs, FP, re-designing
pre-marital consultation, maternal health and perinatal care, addressing violence towards women and
children, uterine, cervical and breast cancer prevention, infertility treatment and health issues
related to menopause.
The evaluation of the 2011-20 National Reproductive Health Strategy noted that FP and contraception
policies need to reach more women, antenatal and postnatal care should be enhanced, and more
skilled medical personnel are needed to assist women during labour, especially for poor women
living in rural areas and deprived regions148. Key informants identified the following implementation
barriers: limited coordination and integration of the various SRH services, lack of awareness of
the strategy by health care professionals, limited and fragmented statistical capacity impacting
on monitoring, difficulties in centralising the strategy because of long-standing specialised
programme addressing aspects of SRH such as the FP programme, lack of funding to fully
147 Morocco Ministry of Health (2011) National Reproductive Health Strategy 2011-2020
53
implement the strategy and need to collaborate with international organisations to support
implementation costs, lack of experienced medical professionals in regions and lack of an
action plan before implementing the strategy149. Box 2 contains the recommendations from the
evaluation.
Box 2: Evaluation of the Moroccan 2011-20 National Reproductive Health Strategy
The evaluation of the Moroccan 2011-20 National Reproductive Health Strategy based on interviews with key
informants provided the following recommendations:
• Form a National Task Force to promote and coordinate activities related to reproductive health education.
• Improve coordination of actors and institutions in the areas of reproductive health
• Educational programmes on various SRH topics have been implemented separately (on STIs, maternal health)
but there is a need to integrate the overall SRH educational programme
• Evaluate the level of knowledge of health professionals before designing the educational plan and capacitate
health professionals in gender principles and SRH issues (obstetrics, nurses and doctors) and medical students
by integrating a SRH module in medicine faculties
• Community engagement in gender and SRH training
• Conduct SRH research:
1. identify barriers to integration of SRH education and services;

2. include all women in reproductive age, not only married women in future surveys;
3. conduct a cost-benefit analysis on implementing SRH education and servicers versus not implementing it;
4. identify the impact of improved SRH services on unwanted pregnancies; and
5. identify the savings that investing in women and children’s have on productivity, education and the economy.
• Increase the effectiveness of SRH communication campaigns (materials and content) targeted to the general
public.
Source: Abaacrouche, M & UNFPA’s technical support (2020) 2011-20 Evaluation of the National Reproductive Health
Strategy
149 Abaacrouche, M & UNFPA’s technical support (2020) Evaluation of the National Reproductive Health Strategy 2011-2020
54
Bangladesh
Bangladesh is a low middle-income country aspiring to become a middle-income country by 2021.

The population in 2018 was 161.4 million, with 37% living in urban areas150. Bangladesh is one of
the most densely populated countries in the world151. The 2014 Bangladesh Demographic Health
Survey noted the population growth rate as 1.37%152. Strong growth and rising incomes have
enabledBangladesh to make significant progress against most human development indicators153.
FP indicators continue to improve: TFR decreased from 2.3 in 2014 to 2.0 births per women in 2018,
the AFR decreased from 113 in 2014 to 82 per 1,000 births in women age 15-19 years, and the CPR
(all methods) increased to 62%. However, women’s low status, the prevalence of child marriage,
and high maternal mortality and morbidity rates remain serious concerns. The largest reproductive
segment (15-24 years) constitutes a significant proportion of the total population. Bangladesh has
low levels of secondary and postsecondary education enrolment. 59% of women (20-24 years) marry
before 18 years. These data indicate that SRH education and services are low among the youth.
Despite successes in health indicators, challenges remain in achieving universal access to SRH services,
partly because of the persistent unmet need for FP (12%), particularly tamong unmarried adolescent
girls154. Annually, nearly one (1) in three (3) pregnancies (1.3 million) are terminated, although
abortion is illegal in Bangladesh, except to save a woman’s life155. Bangladesh has the highest
prevalence of child marriage in South Asia, including girls under 15156. Child marriage has begun
to decline, but not fast enough to eliminate the practice by 2030 as part of the SDGs.
Bangladeshi society is conservative. There are strong religious sensitivity and socio-cultural taboo
attached to sexuality. Although extramarital sex is forbidden, studies reveal diverse sexual practices
and behaviours practised both within and outside marriage, particularly among the youth. Their lack
of adequate SRH information and services often leads to risky behaviours157. The learning scope from
parents, guardians, elders and peers is also very narrow due to conservative views rooted in the
culture158.

152 ARROW (2016) Bangladesh Advocacy Brief: Comprehensive Education: the way forward
153 World Bank data (2020) Bangladesh country update
154 ARROW (2017) Bangladesh Country Profile on Sexual and Reproductive Rights
155 ARROW, Country Advocacy Brief (2016): Bangladesh. Comprehensive Sexuality Education: The Way Forward
156 UNFPA-UNICEF 2017 Annual Report Country Profiles: Global Programme to Accelerate Action to End Child Marriage
55
Bangladesh’s commitment and response to FP are based on human rights principles and aligned
with the international frameworks on the UN Convention on the Rights of the Child (CRC)159, ICPD
PoA, the Beijing Platform for Action and the SDGs. Post ICPD, Bangladesh formed a National
Committee and developed a National PoA for implementation of ICPD PoA form. The National
Committee formulated national policies on Population, Maternal Health, HIV/ AIDS and STD
and Population, Health & SRH and Nutrition160.
The most recent FP related policies include the 4th Health, Population and Nutrition Sector
Programme Plan (4th HPNSP) 2017-22161, led by the Ministry of Health and Family Welfare. The
4th HPNSP prioritises FP as a path toward achieving the SDGs and is supported by the National
Strategy for Adolescent Health 2017-30162. It also aligns with the Constitution, which guarantees
the right to health care and medical treatment for all its citizens, irrespective of age, sex, caste,
creed and colour163. Several Acts of Parliament guide the 4th HPNSP, including the Children Act
2013, Women and Children Repression Prevention Act 2000 (amended in 2003), Human Trafficking
Prevention and Deterrence Act 2012, and the Child Marriage Restraint Act 1929 (amended in
1983)164.
The National Plan for Sexual and Reproductive Health is a costed integrated 5 yearly national plan
which prioritises access for key groups aligned with ICPD and SDG objectives to address reproductive
health and rights, youth development, and gender equality challenges165. Bangladesh prioritised
implementing the National Action Plan for Postpartum FP, reducing social and geographical disparity
through providing regional FP packages in Sylhet and Chittagong divisions, addressing unmet need
among adolescents and youth by operationalising the national adolescent health strategy and
ending child marriage.
Bangladesh has strengthened its efforts to increase trained service providers, including deploying
midwives to all sub-district hospitals, improving supervision of FP services by placing clinical teams in
all districts and engaging the private sector to address gaps in service provision and supply of
commodities.
159 UN (1989) Convention on the Rights of the Child

160 UNFPA (2010) The Bangladesh Family Planning Programme: Achievements, Gaps and the Way Forward
161 PMMU (2017) Program Implementation Report 2017 of the 4th Health, Population and Nutrition Sector Program
162 Bangladesh Directorate General of Family Planning (2016) National Strategy for Adolescent Health 2017-2030
163 Bangladesh (1972) Constitution of 1972, Reinstated in 1986, with Amendments through 2014
164 PMMU (2017) Program Implementation Report 2017 of the 4th Health, Population and Nutrition Sector Program
165 USAID and partners (2020) Policy Brief: Costed Implementation Plan for 2020-2022 National Family Planning Program in Bangladesh
56
3. Costed Implementation Plan for the National Family Planning Programme
The Bangladeshi Government (Programme Management and Monitoring Unit, Ministry of Health
and Family Welfare and the Directorate General of Family Planning) with the support of UNFPA
developed the 2020-2022 CIP. The development process involved a desk review of international
and national evidence, a literature review of high-impact practices, consultation with stakeholders, a
review of CIPs of other developing countries, and consultation with international CIP experts166.
The key strategies and activities for achieving the FP goals costed for three (3) years (2020-22 of
the remaining 4th HPNSP) include:
• Strengthening service delivery provision in existing facilities (service coverage, current and new
FP commodities, and human resources).
• Increasing acceptability of LARC & PMs through skilled human resources and male engagement.
• Promoting interval and post-partum contraception.
• Intra- and inter-sectoral collaboration and coordination including NGOs.
• Special focus on hard to reach and urban areas, and other low performing areas.
• Monitoring, Evaluation and Research.
• Targeting adolescents and youth.
• Targeting adolescent with special focus on males.
Despite achieving remarkable progress, several FP related challenges require immediate attention:
child marriage, high unmet need for adolescents, underserved urban slums, limited human resources,
collaboration across implementing agencies and unequal gender norms. Additionally, new strategies
to improve FP indicators to achieve the national level targets need to be implemented167.
The Population Council Review of Programmes in Bangladesh168 noted that the standard government
health facilities SRH information package for adolescents includes: physical and mental changes
during puberty, general and menstrual hygiene, early marriage and reproductive health, birth control
and violence against adolescent girls and boys.
168 Ainul S, Bajracharya A, Reichenbach L (2016) Adolescents in Bangladesh: Programmatic approaches to sexual and reproductive health education and services.
Situational Analysis Brief. Population Council
57
Most health facilities excluding Community Clinics have FP commodities and equipment, but only
40% can offer modern FP services169. General health care facilities provide youth-friendly services
via Adolescent Friendly Health Centres to reduce stigma and other barriers experienced by unmarried
girls when accessing health service. However, usage rates have not improved, and there are calls for
awareness raising among adolescents’ teachers and guardians. Furthermore, the policy environment
favours delivering clinical SRH services only to married adolescents170.
Country Comparison of Family Planning Policies, Programme and Indicators
This section compares the FP policies, programme and indicators of the selected countries. The Family
Planning Effort Index (FPE)171, which estimates the strength of National FP Programmes and the
National Composite Index on Family Planning (NCIFP)172, which measures the existence of FP
policies and programme implementation, were utilised to undertake the comparison. Table 5
describes the two (2) published data sources.
Table 5: Indexes for Comparing Family Planning Policies and Programme Across Countries
Data source Description
The Family • The only data source measuring national FP programmes using a standard set of
Planning Effort questions across countries and over time. Equated to “how good an FP
Index (FPE) analysis programme is" in each country.
of national FP • Index indicator score quantifies the strength of National FP Programmes as
programme perceived by knowledgeable observers.
• It measures the level of effort put into nation FP programmes worldwide and
tracks how this changes over time¹⁷³.
• Collected via questionnaires administered to 10-15 highly informed
respondents per country (MoH, International Planned Parenthood Federation
affiliate or NGO; international consultants, and other informed individuals).
• Includes 30 measures of effort across four (4) dimensions (policies, services,
evaluation, and method access). Researchers convert the responses to these
questions to individual scores (ranging from 1-10) for each of the 30 items, using
an established set of rules.
173 Measure Evaluation (2020) Family Planning Program Effort Index
58
• The Index serves several important purposes:

i. It enables cross-national comparisons of FP programmes across four (4) key
components: policies, services, evaluation, and access over time
ii. It traces the evolution of the FP programme in a given country over time; and
iii. It measures FP programme input, independent of outcomes (such as
contraceptive prevalence or fertility).
• It attempts to measure the effort (input) that goes into the FP programme, not
the results achieved.
The National • Collected in 2017 and 2014, built on the FPE, the data are intended for policy
Composite Index on and planning use by each country’s FP stakeholders.
Family Planning • Provides new data about key areas important to FP but have not been well
(NCIFP) tool measured in the past.
developed to • It measures the existence of policies and guidelines, as well as the extent to
support FP 2020’s which FP programme implementation includes measurable dimensions of
efforts to improve quality service provision¹⁷⁴.
the enabling • Collected via questionnaires administered to 10-15 highly informed
environment for FP respondents per country (staff of government FP programmes, local NGOs, local
academic or research institutions, and international agencies working locally).
Questionnaires consist of 35 items organised under five (5) dimensions:
i. Strategy: Do they include important elements (e.g. quantified objectives,
focus on vulnerable populations, etc.)?
ii. Data: data collection (service statistics, monitoring sub-groups, etc.) to
inform decisions.
iii. Quality: Do services meet WHO standards? Are quality of care indicators
monitored?
iv. Equity: Related to discrimination, efforts to reach under-served groups, and
v. wide-spread access to FP methods.
Accountability: Focused on monitoring and addressing issues related to
coercion and denial of services and ensuring voluntarism and informed
choice.
• The total score is the average of 35 individual scores for each country. Unweighted
average in 2017 across all countries is 65 (out of 100 representing very strong
effort), an improvement from 53 in 2014.
174 Weinberger, M. & Ross, J. The National Composite Index for Family Planning (NCIFP), Avenir Health’s Track20 Project
59
• Despite differences between countries, there are similarities among the 35

individual scores: they tend to move together, agreeing largely in which rank
higher and lower. The scores suggest commonality in what programmes find
more or less difficult to achieve and is one of many promising avenues for further
investigation.
• Looking at the five dimensions, there is some variability, but less than was seen
in 2014. Strategy continues to score the highest (74), and accountability the
lowest (60). The greatest improvement has been seen in Accountability, up 21
points from 2014. The smallest change was seen in equity, which only increased
by 4 points between 2014 and 2017.
• A valuable source of information for the global FP community informing
qualitative assessments of FP programmes and as a tool to stimulate and
facilitate discussions among stakeholders about the factors that contribute to
a strong FP programme, and whether there is agreement on perceptions of
quality and equity.
1. Findings from the 2014 National Family Planning Effort Index comparison
The overall FPE score measuring efforts into the FP programme (and not the results achieved) across four
(4) dimensions (policies, services, evaluation, and method access) was highest for Bangladesh (65.9),
closely followed by Malaysia (63.2), Morocco (61.5), Egypt (50.1) and Turkey (38.5) (Appendix 4)175.
The best score for the formulation of policies was for Bangladesh (72.1), closely followed by Morocco
(70.1), Malaysia (59.5), Egypt (53.5) and Turkey (38.6). In summary, Malaysia could significantly improve
on all FP-related policies when compared to Bangladesh, Morocco and to a certain degree Egypt.
The policy objectives reflect the current population strategies in Malaysia and Turkey (26.3 and
20.7 respectively), which shifted in recent years to encourage higher fertility rate, while Bangladesh
(88.1) and Egypt (81.7) are focusing on reducing the population growth.
Regarding services provision, both Bangladesh (60.9), Malaysia (60.3) and Morocco (59.6) had the
highest scores, with Egypt (49.8) and Turkey (30.3) lagging behind. Malaysia is doing well to involve
civil bureaucracy, postpartum programmes, training programme, personnel undertaking assigned tasks,
logistics and transportation, and system supervision compared to the other countries.
60
Regarding the evaluation, both Morocco (77.5) and Malaysia (73.3) had the highest scores, with
Bangladesh (66.7), Egypt (53.7) and Turkey (53.0) lagging behind. Compared to the other countries,
Malaysia is doing well across all the evaluation components, including record-keeping systems,
programme evaluation and management’s use of evaluation findings.
Malaysia is doing well in focusing on certain vulnerable populations (the poor, rural populations
and post-partum women).
Bangladesh (66.7) and Malaysia (62.2) had the highest scores for accessibility, with Morocco (53.7),
Egypt (47.2) and Turkey (43.8) lagging behind.
Malaysia is doing well in the accessibility to a range of FP commodities, including contraceptive

pills, injectables, condoms, permanent sterilisation and IUD removal when compared to the
other countries.
2. Findings from the 2017 National Composite Index on Family Planning Comparison
The overall 2017 NCIFP score176 builds on the efforts from the 2014 NFPE. It measures the existence
of policies and guidelines, as well as the extent to which FP programme implementation includes
measurable dimensions of quality service provision (strategy, data, quality, equity and accountability).
Bangladesh had the highest score (63.0), closely followed by Egypt (61.6), Morocco (59.5) and
Malaysia (58.4). Data for Turkey was not available for this Index (Appendix 4).
All compared countries were of a similar rating regarding FP Strategy; Bangladesh (78.0) was the
highest, followed by Malaysia (67.7), Egypt (67.6) and Morocco (65.9). Malaysia is doing well in
reaching vulnerable populations with quality FP info and services, projecting resource needs
(material, human and financial) to implement the FP Strategy, developing a plan to secure the
resources, getting high-level FP support from the Director of the National FP programme and
reporting to government, when compared to the other countries.
Malaysia ranked highest for the data score (67.1), followed by Egypt (63.2), Morocco (60.1) and
Bangladesh (53.6). Malaysia is doing well in collecting data regarding service statistics quality control,
the adequateness of clinical record keeping, using data for monitoring (programme statistics,
national surveys, and small studies) by programme managers for programme improvement compared
to the other countries.
61
Both Egypt and Bangladesh had the highest score for quality (62.9 and 62.6, respectively), followed
by Morocco (60.0) and Malaysia (53.7). It had consistently low scores across most components,
particularly in the following areas: producing Indicators of Quality of Care (QOC) collated by both
the public and private sector FP services, producing task-sharing guidelines for the delivery of FP
services, establishing structures to address QOC (including participatory monitoring and community/
facility quality improvement activities), providing information on informed choice and provider
bias collected by the government, training for FP personnel to effectively undertake tasks, optimal
FP logistics and supply system to keep stocks of contraceptive supplies and related equipment
available at all service points, at all times and at all levels (central, provincial, local), optimal supervision
system at all levels (regular monitoring visits with corrective or supportive action), and access to
implant removal.
Bangladesh had the highest score for accountability (65), followed by Egypt (62.5), Morocco (57.8)
and Malaysia (49.7). Accountability is another priority area for improvement in Malaysia, as it had
consistently low scores across all components. The components included monitoring mechanisms
at national, subnational, and facility-level to monitor access to voluntary non-discriminatory
FP info and services, report denial of services on non-medical grounds (age, marital status, ability to
pay), coercion (including inappropriate use of incentives to clients or providers), regular review of
violations, and mechanisms for feedback from clients, providers and officials about service
availability, accessibility, acceptability and quality.
Both Bangladesh and Malaysia had similar scores for equity (56.8 and,55.2, respectively),
followed by Morocco (51.6) and Egypt (55.2). Malaysia is doing well in addressing provider
discrimination and providing access to short-term methods of contraception compared to other
countries.
62
DISCUSSION
FP’s mobilisation reflects the international consensus that universal access to FP is key to ensuring a
woman’s right to regulate the number and spacing of births, achieving women’s empowerment and
gender equality, and reducing poverty.
FP should be integrated within the SRH policy and programming framework that includes CSE,
prevention and treatment of STIs and HIV/ AIDS, and perinatal care.177 SRH information and
services should be integrated within PHC services as there are proven benefits in gender equality,
MCH and HIV prevention178,179. Improved access to SRHE and modern contraception improves
adolescents’ chances of achieving higher education levels, delay childbearing and greater ability to
engage in an income-producing activity180. Governments should ensure that FP and SRH services
are safe, reliable, convenient, available, accessible, cost-effective/affordable, culturally acceptable
and inclusive of all individuals, regardless of gender, marital status, age, sexual orientation or
religion181,182. All countries face the challenge of addressing the unmet need for FP and providing
pregnant women and newborns with the standard quality of care recommended by WHO. This
would improve developmental indicators183.
Family Planning Best Practices
National reproductive health policies provide a broad vision and framework for government
action. The policies should strive for universal access to a wide range of sexuality education and
FP/SRH services across the life course184. FP is increasingly being incorporated into national
development plans as part of SRH and rights, although with limited and variable extent and scope185.
UNFPA’s Family Planning Strategy 2012-20186 guides implementing a rights-based FP policy and
programme for countries to allow individuals and couples to choose whether, when and how
many children they have.
178 United Nations, Commission on Population and Development, Forty-Fourth Session, 11-15 April 2011, Report of the Secretary-General entitled Fertility,
reproductive health and development. E/CN.9/2011/3.
182 WHO (2017) Global Accelerated Action for the Health of Adolescents (AA-HA!): guidance to support country implementation
183 Shrestha BD, Ali M, Mahaini R, Gholbzouri K (2019) A review of family planning policies and services in WHO Eastern Mediterranean Region Member States.
East Mediterr Health J 25:127–133.
184 ARROW (2019) Brief: Universal Health Coverage and Integrating SRHR. Asian-Pacific Resource & Resource Centre or Women
63
Family Planning Policies and Programme Across Selected Countries
The ICPD PoA notes that individual countries have the sovereign right to contextualise policies and
programme to conform to customary laws, values, and cultures as long as they uphold individual SRH
rights and principles and respond to individuals’ needs187. Expectedly, this review noted that countries
differ in their commitments to SRH rights and FP principles, adaptations, implementation and progress
measurement. Past and current data across the selected countries indicate that reproductive
health is a crucial public health issue. These countries, particularly Malaysia, have made remarkable
progress in human and economic development. The countries have legal and policy frameworks for
SRH for matters such as the age of marriage, abortion and gender-based violence.
The national population goals across countries often direct the FP policy direction, which might
encompass certain key aspects of SRH rights, such as access to SRH services or the ability to decide
one’s health188. Following the ICPD and Beijing, all selected countries except Malaysia consider
FP a component of a broader SRH plan189. Integration in an SRH plan facilitates the linkages with the
SRH rights and principles and strengthens the policy or plan overall. There are notable policy and
programme weaknesses when measured against international guidelines and best practices.
Examples include the lack of or weak policies for vulnerable populations and the exclusion of the
role and responsibilities within the family unit. The latter example increases the pressure on women
as primary carers and decreases their ability to participate in the workforce.
National FP goals vary across countries; Malaysia, Turkey and Morocco introduced contraceptive
programmes in the past decades, which reduced the TFR to replacement rate by 2018. The three
(3) countries’ populations are projected to decrease. The projection has resulted in a shift in their
population strategies to encourage higher fertility. The aim is to prevent an economic environment
typical of developed nations, an ageing population with a high dependency ratio and a shrinking
working-age population. In contrast, overpopulated Egypt and Bangladesh are still focusing on
controlling the population growth affecting their limited resources.
The prioritisation of FP and SRH issues within the national agendas is influenced by the wider socio-
cultural contexts. Across examined countries, and Malaysia in particular, less controversial SRH
services such as perinatal care services seem more likely to get buy-in from key stakeholders, compare
with sensitive services such as safe abortion or GBV services, which require specific strategies to
transform socio-cultural norms, beliefs and behaviours190.
188 Guttmacher Institute (2015) Onward to 2030: Sexual and Reproductive Health and Rights in the Context of the Sustainable Development Goals. In: Guttmacher
Institute.
190 Lim, SC. Yap, YC. Barmania, S. Govender, V. Danhoundo, G & Remme, M. (2020) Priority-setting to integrate sexual and reproductive health into universal health
64
Domestic politics across the selected countries determine whether, how, and to what extent a
rights-based approach to SRH and FP framework is implemented191. Political contestations over SRH
rights continue across the selected countries, despite differences in their overall social attitudes
to sexuality and reproductive health. Increasing Islamic division on sexual health issues is echoed
in domestic politics; however, the strength and the specific form differ. Egypt has been particularly
successful in engaging religious scholars in FP campaigns, a critical factor for sensitising
populations. The Al-Azhar Mosque and the Al-Azhar University regularly issue fatwas favouring
modern contraception with available in all government PHC facilities192. In contrast, Turkey’s
conservative political turn since the early 2010s193 has restricted FP services for women194. The
restrictions are impacting policymaking, implementation, and civil society activities on rights-based
sexual health promotion. Turkey has a pronatalist direction within the most recent Four-Year
Development Plan195, which encourages women to bear a minimum of three (3) children.
Turkey did not participate in the WHO’s Action Plan for Sexual and Reproductive Health on
the 2030 Agenda for Sustainable Development in Europe196. The country’s centralised health
governance also makes Turkey’s SRH policies vulnerable to abrupt changes.
Family Planning Service Delivery Across Selected Countries
Religion remains a critical influence on FP, although its direction (progressive or conservative) varies
by country. Misconceptions based on religious precepts significantly contribute to the insufficient
progress towards implementing FP services. Islamic religious beliefs and cultural views on family
ize influence the acceptance and use of contraception. Uninformed views highlight the need to
sensitise and engage religious scholars in FP efforts197. Additionally, premarital sexual relationships
across selected countries are forbidden by Islamic Law and unapproved by society. However,
premarital sexual relationships do occur. FP and SRH education and services for youth are required
urgently to avoid the risk of STIs and unwanted pregnancies.
194 MacFarlane KA, O’Neil ML, Tekdemir D, et al (2016) Politics, policies, pronatalism, and practice: availability and accessibility of abortion and reproductive
health services in Turkey. Reproductive Health Matters 24:62–70.
65
FP services are part of the basic health benefits package and are delivered at hospitals, PHC
centres and/ or outreach clinics. Despite efforts to integrate FP programme into PHC, access to FP or
contraceptive services and equity issues remains a challenge, particularly for vulnerable populations.
Across Egypt and Bangladesh, the desired result of fertility control was not achieved, especially
amongst rural women. Implementation barriers among these low-income countries include lack of
infrastructure, stock shortages, lack of trained staff, and cost of contraceptive methods that lead
to limited access among vulnerable groups. In Malaysia and Turkey, the low fertility rate combined
with pronatalist policies presents challenges regarding access to and use of contraception for all
populations, particularly for young people198.
The use of modern contraception also varies significantly across and within the selected countries.
Common implementation challenges include providing services to hard-to-reach areas; Turkey,
Morocco, and Egypt have challenges in addressing geographical disparities in service provision
and access. Rural areas are disadvantaged and have worse FP/SRH. Addressing AFR also presents a
challenge. Egypt has committed to investing in empowering girls to address this problem.
Accessibility barriers to FP services are also linked to conservative religious social attitudes and
contribute to high adolescent pregnancy rates199. Since SRH research, education and services are
commonly targeted to married couples, unmet need for contraception among young people is
underestimated. A 2020 desk review across the same selected countries concluded that
implementation of SRH education in schools and the community is poor200.
Large disparities within countries in CPR and unmet need for FP are associated with poverty,
younger age, gender (female), geographical location (urban vs rural) and marital status (unmarried).
Approaches to reducing unmet need for FP should be contextually and culturally sensitive201.
Countries should work on reducing unmet need by addressing both the demand for and supply
of FP services202.
Other vulnerable populations such as people living with HIV and sex workers often face compounded
access barriers and rights violations, leading to high rates of unintended pregnancy, increased
risk of HIV and STIs, limited choice of contraceptive methods, and higher levels of unmet need
for FP. These groups require particular attention to ensure their reproductive rights and access to
rights-based FP services203.
200 Ghani, F. and Awin, N. (2020) Sexuality Education across selected Muslim countries: A review to inform Malaysia’s 2020-24 National Reproductive Health and
Social Education Plan of Action, United Nations University International Institute for Global Health (UNU-IIGH), commissioned by UNFPA.
202 UNFPA (2012) Women’s Need for Family Planning in Arab Countries
66
Rational utilisation of existing limited national resources is a major challenge to improving
reproductive health across countries. Following best practices and with international support, Egypt
and Bangladesh have developed SRH strategies accompanied by CIPs. Malaysia would greatly
benefit from producing a CIP to accompany an updated FP Strategy. Additionally, since FP benefits are
shared across portfolios and drive many SDGs, these costs could be co-shared across ministries.
Monitoring and Evaluation
Monitoring and evaluation are crucial in determining progress and the quality of implementation of
national strategies. A well-functioning monitoring and evaluation framework developed before
implementation is essential to assess programme effectiveness and make recommendations for further
improvements204. Documented best practice in FP suggests the need for close coordination and
collaboration among stakeholders in scaling up best practices to improve MCH205. Malaysian FP
indicators should also align with WHO’s reproductive health indicators to enable global monitoring
and international comparisons (Box 3)206. Finally, COVID-19 is a disruptive phase for essential health
services, significantly impacting on FP services. Each selected country should consider an appropriate
response depending on how the pandemic unfolds and what choices women make about their
continued contraceptive use207.
Priorities for Family Planning in Malaysia
This desk review highlights the policy and programmatic gaps for Malaysia. It includes recommendations
to strengthen FP services to improve maternal and infant health outcomes and meeting Malaysia’s
international commitments208.
While Malaysia has several strategies related to FP, it would greatly benefit from devising a broader
rights-based SRH plan aligned with the national population policy and other related policies. The
alignment of policies will ensure congruence and comprehensiveness of goals and strategies,
focusing on addressing the FP and SRH needs of the youth and other vulnerable groups. The 2nd
Malaysian Population Strategic Plan Study 2010209 advocates for a family-centred approach to
Malaysian development planning. While this Plan recommended a strategic framework for
204 The countries included Afghanistan, Egypt, Iraq, Jordan, Lebanon, Morocco, Oman, Qatar, Pakistan, Palestine, Saudi Arabia, Somalia, Sudan, Syrian Arab
Republic, Tunisia and Yemen. Six countries did not respond; Bahrain, Djibouti, Islamic Republic of Iran, Kuwait, Libya and the United Arab Emirates.
205 Kabakian-Khasholian T, Quezada-Yamamoto H, Ali A, et al (2020) Integration of sexual and reproductive health services in the provision of primary
health care in the Arab States: status and a way forward. Sex Reprod Health Matters 28:1773693
206 Measure Evaluation (2020) WHO’s short list of reproductive health indicators for global monitoring
207 Weinberger, M. Hayes, B. White, J. & Skibiak, J. (2020) Doing Things Differently: What It Would Take to Ensure Continued Access to Contraception
During COVID-19 Global Health: Science and Practice
208 Malaysian Government (2019) Accelerating Malaysia’s Progress Towards Implementation of ICPD Programme of Action. In: Nairobi Summit.
67
implementing future population and development programme guided by the principles of gender
equity, respect for human rights and family values, it failed to mention the youth. Nevertheless,
the 2010 Plan provides relevant recommendations to address current challenges in Malaysia (such
as fertility decline, reproductive health, family and gender issues and demographic trends) within
a strategic population framework. NPFDB’s 2018 Situational Analysis on Population and Family in
Malaysia210 also proposes several strategies to reverse the fertility decline by exploring sub-fertility,
pro-fertility incentives, childcare options and flexible working arrangements for mothers.
Although considerable progress has been made in Malaysia regarding FP, the agenda remains
unfinished. The MoH aims at providing free FP services without discrimination to all regardless
of age, religion, ethnicity, marital status, and non-citizens must abide by the Fee Act211.
However, the 2019 CEDAW review212 noted that despite some positive changes in law
and policy, there had been no significant shift in women’s status regarding exercising their
reproductive rights, including the timing and spacing of childbearing. Malaysian women still
experience availability, accessibility and affordability barriers to high-quality services,
particularly abortion services. The barriers disproportionally affect vulnerable women and
girls (unmarried youth, refugees, indigenous, migrants, transgender and prisoners).
Across the examined countries, Malaysia had the lowest CPR and highest unmet need for FP,
despite contraception services being integrated into PHC and made available for all youth
and women at government clinics.
The low CPR and unmet need are partly attributed to SRH services not being adequately
promoted and fear of stigmatisation and discrimination, particularly for adolescents213.
Malaysia’s efforts reduced the adolescent fertility rate from 28 births per 1,000 girls aged
15-19 years in 1991 to 8.5 births in 2018, the lowest across selected countries. However,
teenage pregnancy remains a significant health and socioeconomic concern. Despite the
exception to the prohibition of abortion in the Malaysian Penal Code, unmarried girls
may resort to illegal abortion or baby dumping due to access barriers: the requirement
for parental consent for those under 18 years, uninformed advice from health workers.
Abortion laws and clinical guidelines should be reviewed to ensure congruence between
service availability, affordability and accessibility for high-risk groups.
Additionally, there is limited comprehensive, integrated and up-to-date FP and SRH data to inform
planning. The 10-yearly MPFS, the most recent dating from 2014214, captures national FP data from

211 As advised by the MoH representative to the TWC
68
married women only (overestimating CPR and underestimating unmet needs). More regular and
comprehensive FP data including unmarried people and disaggregated by age, sex, economic status
and location is required to measure trends and changes in knowledge, attitudes and sexual practices
(such as safe sex and use of FP methods) to inform adequate FP policy and programmes.
A recent Malaysian study examining the integration of SRH into universal health coverage (UHC)
processes identified several strategies triggering buy-in from key stakeholders within the Malaysian
context including generation of public demand and social support; placing SRH issues on the public
agenda or linking them with international commitments; engaging with champions within
government; and reframing SRH issues to appeal to existing values and beliefs. However, sensitive
services such as safe abortion or GBV services require specific strategies to transform socio-cultural
norms, believes and behaviours215.
LIMITATION
This review faced several challenges, including limited time and resources. The published information
on FP policies and programme across the selected countries was limited. Governments might not have
published FP related policies and action plans, in which case, secondary data sources referring to these
policies were used, including UNFPA country reports. In addition, policies were written in languages
other than English. Translation was done for official documents from Malaysia and Morocco.
CONCLUSION
SRH rights-based FP planning and programmes are a cost-effective public health measures and
development interventions for accelerating the SDGs. National policies and programmes should
endorse FP and SRH rights to achieve national targets and meet international commitments.
The selected countries, particularly Malaysia, have made remarkable progress in human and economic
development. The SRH legal and policy frameworks have either been drafted or are being drafted.
Malaysia, Turkey and Morocco are currently encouraging higher fertility rates to prevent a projected
economic slowdown, while overpopulated Egypt and Bangladesh are still focusing on controlling
the population growth.
69
Most of the selected countries consider FP a component within the SRH plan, rather than an isolated
policy, facilitating the linkages with the SRH rights and principles. However, despite progress in several
FP policies and services, the selected countries still face challenges in implementing FP programmes.
Domestic politics determine whether, how, and to what extent SRH rights and FP framework is
implemented. Egypt has a more liberal interpretation of FP within the Islamic framework, while Turkey
has become more conservative in recent years, which impacts FP/ SRH service provision.
Across examined countries, less controversial SRH services such as perinatal care services are more
likely to get buy-in from key stakeholders, compare with sensitive services such as safe abortion
or GBV services, which require specific strategies to transform socio-cultural norms, beliefs
and behaviours. Integration of comprehensive FP and SRH services into national health policies
and strategies requires identifying policy windows and enabling conditions to advance specific SRH
interventions as well as regular re-prioritisation to ensure no one is left behind216.
In Malaysia and Turkey, low fertility combined with pronatalist policies presents challenges
regarding access to and use of contraception for all populations, particularly for young people.217
Policy and service gaps were also identified for key vulnerable groups including adolescents, the
unmarried, poor, those with disabilities, older people and those living in rural or remote areas. The
accessibility barriers are compounded when looking at the intersectionality of these characteristics.
Vulnerable groups require particular attention to ensure their reproductive rights and access to
rights-based FP services218. Following best practice and with international support, Egypt and
Bangladesh have developed SRH strategies accompanied by CIPs to ensure the rational utilisation of
existing limited national resources. A CIP would also benefit Malaysia.
Malaysia had the lowest CPR and highest unmet need across selected countries, despite an FP
programme integrated into PHC, slowing the achievement of the SDG 3 targets by 2030. Ensuring
universal access to SRH services, FP, IEC, and the integration of reproductive health into national
strategies and programme should be addressed as a priority on the national agenda. Special
programmes for vulnerable populations (adolescents, refugees and persons with disabilities) should
be streamlined and strengthened219.
The desk review proposes the development of a comprehensive FP policy aligned with internationally
endorsed FP principles and guidelines.
coverage – The Case of Malaysia (accepted manuscript)
219 Shrestha BD, Ali M, Mahaini R, Gholbzouri K (2019) A review of family planning policies and services in WHO Eastern Mediterranean Region Member States. East
Mediterr Health J 25:127–133.
70
RECOMMENDATION
The following recommendations are proposed for consideration regarding Malaysia’s FP Policy based
on the findings of this desk review.
1. Consider FP a component within a broader SRH plan under the existing National
Population Policy currently reviewed by NPFDB and the Policy Division with MWFCD
rather than an isolated policy, ensuring a life-course approach to FP and SRH services that
encompasses UNFPA’s recommended SRH components220. The components include FP
services, adolescent SRH, CSE, abortion and management of complications, prevention and
treatment of STIs, perinatal care and SRH programmes and services for the elderly221.
The strategy should be accompanied by a CIP stating the roles and responsibilities of relevant
government agencies in its implementation.
2. Ensure a rights-based FP policy and programmes by formulating operational policies to

prevent discrimination towards stigmatised groups (unmarried youth, people living with
HIV/ AIDS, sex workers), providing equitable community-based distribution of contraceptives
for hard to reach areas.
3. Engage in participatory policy formulation by defining FP objectives over a 5-10 year

period with quantitative targets, particularly on reducing unmarried adolescent childbearing
as well as maternal and infant mortality, increasing the participatory engagement of key
stakeholders (including NGOs, academics and civil society) and strengthening the laws and
regulations facilitating contraceptive supplies. Continue strengthening the policies on fertility
and age at marriage (an ongoing process), import laws and legal regulations and advertising
of contraceptives, and ensure favourable statement by political leaders at least 1-2 times
per year.
4. Advocate FP for improving mother and child health across all future FP interventions
among key stakeholders, particularly community and religious leaders, following the lead
of Egypt and based on Malaysia’s MoH policies and service delivery. Spacing births via
contraception is not prohibited by the Quran and enables a logical timeframe for the mother
to regain her physical strength and for each child to receive appropriate attention for their
nourishing, training, and education221.
220 Williams K, Warren C, Askew I (2010) Planning and Implementing an Essential Package of Sexual and Reproductive Health Services: Guidance for Integrating
Family Planning and STI/RTI with other Reproductive Health and Primary Health Services
71
5. Strengthen FP service provision by engaging the private sector to increase community-
based distribution, improve administrative structures and the content of mass media
campaigns, and identify and leverage incentives and disincentives for FP use.
6. Implement CSE to prevent unwanted pregnancies among unmarried youth, as

recommended by a previous desk review223. Teaching CSE to promote informed choices on
safer sex and contraception is primary prevention. CSE has been proven to be more effective
than abstinence-only or abstinence plus programmes in delaying sexual initiation and
reducing the negative health consequences of unprotected sex. Malaysia’s current
abstinence-only-until-marriage approach is based on the harmful misconception that CSE
might encourage early sexual activity and risk-taking behaviours; it provides very limited
information on safer sex and contraception and should be corrected to align with UNESCO’s
CSE curriculum guidelines224.
7. Address the needs of vulnerable populations, particularly the unmarried youth, by

increasing the accessibility to emergency contraception and safe abortion and providing
counselling and contraceptive services for post-abortion women. Reframe abortion services
as a means to reduce maternal and infant mortality by addressing unsafe practices to the full
extent that Malaysia’s legal framework allows.
8. Strengthen the existing accountability mechanisms at national, subnational, and facility

levels to monitor FP information and service availability, accessibility, affordability,
acceptability and quality, particularly for vulnerable populations. The 10-yearly MPFS225
captures national FP data from married women only (overestimating CPR and underestimating
unmet needs). More regular and comprehensive FP data including unmarried people and
disaggregated by age, sex, economic status and location is required to measure trends and
change in knowledge, attitudes and sexual practices (such as safe sex and use of FP methods)
to inform FP policy and programmes.
9. Increase the quality of FP services provided by improving and monitoring Indicators of

Quality of Care (QoC) collated by the public and private sector FP services, strengthening
FP logistics and supply system to keep stocks of contraceptive supplies available at all
service points, at all times and at all levels (central, provincial, local), strengthening
the structures to address QoC (including monitoring, quality improvement activities and
training of FP personnel to support informed choices and avoid provider biases). There
223 Ghani, F. and Awin, N. (2020) Sexuality Education across selected Muslim countries: A review to inform Malaysia’s 2020-24 National Reproductive Health and
Social Education Plan of Action, United Nations University International Institute for Global Health (UNU-IIGH), commissioned by UNFPA.
224 UNESCO (2018) International Technical Guidance on Sexuality Education
72
is a need to identify and address discrimination cases and services denial on non-medical
grounds (age, marital status or ability to pay), or coercion (inappropriate use of incentives
to clients or providers) via regular feedback mechanisms.
10. Review the FP related objectives and recommendations from Malaysia’s 2010 Population
Strategic Plan Study226 (Appendix 3) as part of a roadmap leading to the formulation of
a comprehensive FP policy that addresses Malaysia’s FP gaps (Table 6). The 2010 Plan
advocates for a family-centred approach to FP and proposes establishing a National
Institute for Family and Population to study family dynamics changes and their implications
as done in other countries.
11. Consider becoming an active member of – and a regular contributor to – the Family
Planning 2020 movement. The movement provides many opportunities to learn lessons
across countries and create alliances to strengthen international commitments to designing
and implementing evidence-based FP/ SRH policies and programme.
A roadmap informed by the lessons learned as well as FP guidelines and best practices are provided in
Table 6 to guide the formulation of Malaysia’s FP strategy and programmes.
73
ROADMAP FOR FORMULATING AND IMPLEMENTING
A FAMILY PLANNING POLICY
This section presents a roadmap for developing a comprehensive FP policy for Malaysia based on this
review’s findings. The roadmap (Table 6) may also be useful for other countries. Actioning this roadmap
can be supported by the range of practical resources for FP policy and programmes provided
(Appendix 6).
Table 6: Roadmap for Developing a Comprehensive Family Planning Policy²²⁷
Recommendation Description/Rationale/Lessons learn across countries
1. Conduct a policy • FP policies are the laws, regulations, guidelines, and strategies related to
analysis to understand the management and/or delivery of FP goods and services.
the policy processes • Legislation’s effects on FP in the context of regulating personal status
and identify key issues, fertility, and incentives to FP should be considered²²⁸.
stakeholders as well • Undertake rigorous situation analysis of current efforts and associated
as barriers and gaps in FP and, on this basis, identify and support opportunities for greater
opportunities for policy alignment and coordination of all FP efforts under national leadership²²⁹.
change to inform
strategic planning
2. Engage identified key • Need for improved institutional coordination between health, nutrition
stakeholders in the and population services to avoid duplication, training, nursing services,
process of policy quality assurance, and availability of HR at the facilities.
development and • Develop strategic, more mutually rewarding, long-term partnerships with
clearly define and a wider range of partners, including civil society and private sector and in
agree on their roles alignment with FP objectives²³⁰.
and responsibilities in
implementing the
policy.
227 FP High Impact Practices (2020) Policy: Building the foundation for systems, services, and supplies
228 Al-dakkak MS (1987) The interaction between the legislative policy and the population problem in Egypt. Popul Bull ESCWA 83–94
74
3. Establish or strengthen • Establish effective coordination mechanisms among the national partners
institutional for effective FP programming – supply, demand, access to and quality of
mechanisms for FP care, enabling environments and knowledge management²³¹.
• Interdisciplinary mechanism for intersectoral collaboration.
• Revive the ACCRH by NPFDB, to increase the quality of SRH services by
improving multisectoral collaboration and coordination, ensuring
participatory planning and effective monitoring and overseeing the
implementation.
4. Promote strong • Support good governance for FP: identify, develop, and/ or strengthen
governance and accountability systems for FP that foster cooperation among government,
participatory processes private sector and civil society; support voice and accountability
to support policy programmes for civil society; foster donor collaboration in supporting
reform. strong governance for FP; build on existing FP Technical Working Groups
to focus on governance and accountability; and provide a forum for
discourse and exchange of ideas among key stakeholders to facilitate
policy implementation and prevent problems in communicating policy
ideas.
5. Develop a National FP • A new FP strategy can ensure the optimisation of day-to-day programming
Policy. via improvements in the coordination of action, resources and leadership
Strategic direction to at country level. Governments, stakeholders and external partners bring
balance population extensive experience to the table about what needs to be done to achieve
and development via universal access to FP²³².
inter-sectorial framework • This document should articulate national FP vision, goals and priorities
and implementation and development objectives (consider progress outcomes: GBV prevalence,
plan that guides child marriage, adolescent pregnancies, etc.), set minimum standards of
governmental and quality, outline roles and responsibilities, facilitate coordination, guide
non-governmental resource mobilisation, determine timelines for programme rollout and
interventions. outline reporting requirements including indicators to monitor progress
and correct ineffective strategies.
• The comprehensive recommendations of the 2nd Malaysian Population
Strategic Plan Study 2010²³³ to address fertility decline, reproductive
health, family and gender issues and demographic data issues within a
population strategic plan should be reviewed.
75
• NPFDB’s 2018 Situational Analysis on Population and Family in

Malaysia²³⁴ proposed several strategies to reverse the fertility decline
trend by exploring sub-fertility, pro-fertility incentives, childcare options
and flexible working arrangements for mothers.
• If developing a national macro-level population policy to address the
balance between population growth and development, design an inter-
sectorial framework and implementation plan to guide the governmental
and non-governmental interventions covering multiple sub policy areas
and ensure the integration of the FP goals and strategies. This should
support and complement existing policies such as the National Social
Policy, the National Policy on Women and the National Child Policy.
Priority Areas To Be Considered
In line with leaving no one • Special programme for adolescents, refugees and persons with disabilities
behind, it is recommended need to be streamlined and strengthened²³⁵.
a strategically focus on • In view of the high unmet need for contraception among these women
vulnerable populations aged 40-49, i.e. at the end of their reproduction, special attention needs
when planning the policy to be given to them to prevent unwanted births and abortion²³⁶.
and programme (e.g. • The population that lives in rural and remote areas, i.e. far from health services.
women/girls vulnerable to • The FP-related indicators could be improved (extracted from MoH’s Health
unwanted pregnancies, Facts 2019²³⁷):
disadvantaged rural areas). i. Maternal mortality ratio (per 100,000 live births): 25
ii. Perinatal Mortality Rate (per 1,000 births): 8.7
iii. Neonatal Mortality Rate (per 1,000 live births): 4.4
iv. Infant Mortality Rate (per 1,000 live births): 6.9
Improve SRH service • Train and engage health care workers, parents, peer educators, NGOs,
awareness, delivery, and teachers, community and religious leaders, among others in delivering
accessibility to leave no SRH messages.
one behind. • Expand services availability, accessibility and affordability to all children,
adolescent, and young people and ensure geographical coverage.
• Review and update MoH’s 2012 Guidelines on Managing Adolescents
Sexual and Reproductive Health Issues in Health Clinics to support youth
health services.
234 NPFDB(2018) Situational Analysis on Population and Family in Malaysia

235 Shrestha BD, Ali M, Mahaini R, Gholbzouri K (2019) A review of family planning policies and services in WHO Eastern Mediterranean Region Member States. East
Mediterr Health J 25:127–133.
237 Ministry of Health (2019) Health Facts 2019
76
Priority Areas To Be Considered
• Reframe termination of pregnancy services as a means to reduce maternal

and infant mortality by addressing unsafe practices to the full extent that
Malaysia’s legal framework allows.
• Promote and enforce the guidelines for termination of pregnancy (e.g.
eligibility and permissibility based on a health, psychological and
counselling assessment, and availability and location of services).
A variety of service • Social marketing to bring about behaviour change towards the uptake of
delivery modalities are birth spacing methods.
needed to ensure access to • Approaches to reducing unmet need for FP must we contextually and
a range of FP methods. culturally and respond to the individual practices of users who may, for
example, discontinue use or switch to another method that they deem
more appropriate or that is more reliably available at their local health
facility²³⁸.
Termination of Pregnancy • Although both the Civil and Syariah Laws allow abortion only to protect
• The policy and laws the physical and mental health of the mother, a 2019 review of Malaysia’s
requiring parental consent progress regarding CEDAW noted that abortion is stigmatised and costly
for abortion should review and government hospitals do not often provide the service; information
to facilitate a safe and and counselling from government hospitals use a religious perspective,
confidential environment rather than a reproductive health rights framework²⁴⁰.
to deliver services to • Despite MoH’s 2012 Guidelines for Termination of Pregnancy for Hospitals,
pregnant adolescents²³⁹ the lack of awareness regarding abortion laws in Malaysia among health
• Include medical abortion care providers is likely to lead to illegal and unsafe abortion practices,
care, in the medical school increasing the risk of maternal and infant morbidity and mortality.
curriculum and as part of • The availability of safe abortion depends not only on permissive
ongoing professional legislation but also on political support and the ability of health
training. Health care providers professionals to provide it. Abortion care, including medical abortion,
should be trained to deliver needs to be included in the medical school curriculum²⁴¹.
SRH information (including • MoH is finalising the formulation of an alternative pathway to abortion
abortion exceptions) and (e.g. parenting or adoption) in partnership with KKM, JKSP and JKM. This
services in a confidential pathway is more aligned with the Islamic value system and provides
and non-judgmental and psychological, educational, and economic support networks for families
non-discriminatory manner. via halfway houses.
77
6. Translate the policy • Link it to the six WHO’s health systems building blocks:
into an operational 1) governance and leadership; 2) Health Management Information System;
Plan of Action for 3) Human Resources for Health; 4) service delivery; 5) essential medicines;
policy implementation and 6) financing.
7. Develop a costed • The FP CIP under the FP2020 initiative is to support governments in
implementation plan transforming FP goals into concrete programmes and policies by prioritising
(CIP) to allocate appropriate interventions, allocating limited resources, unifying
resources for policy stakeholders around one plan, and supporting monitoring and
implementation. accountability²⁴². The Guidance for Developing a Technical Strategy for
Family Planning Costed Implementation Plans provides systematic and
practical guidance for articulating the FP goal.
8. Identify and capacitate • Communication and training of managers, administrators and clinicians
the key implementing and updating the pre-service curriculum for clinical staff.
groups. • A competency-based national qualification system is certifying health
workers to ensure a better quality of services.
• Capacity building of Muslim religious leaders.
9. Monitor and evaluate • Ensure systematic approaches that maximise the use of data, build on
policy implementation. evidence, and which effectively monitor and document progress²⁴³. Policy
Regular data collection, monitoring involves (1) appraising the policy environment, (2) gauging the
dissemination, and use level and quality of stakeholder engagement, (3) documenting the progress
of feedback are essential of policy development and the legislative endorsement of the policy, (4)
for assessing progress putting policies into practice through financing and implementation
and making mid-course planning, and (5) evaluating outcomes of implementation²⁴⁴.
corrections. Policy • Establishing a robust M&E mechanism for accountability.
monitoring is a process • To use internationally accepted indicators, as not all the WHO indicators
by which stakeholders on SRH²⁴⁵ are currently monitored. Learn from the M&E recommendation
follow and assess for Egypt regarding building a population-related observatory to monitor
policies to ensure they and evaluate the implementation of the NPS 2015-30 to:
are developed, i. Collect and harmonise the available data and indicators and evaluate
endorsed, enacted, and the strategy; and
implemented as ii. Assess and bridge the information gaps by new surveys or innovative
intended. research methods such as crowdsourcing and big data methodologies.
244 USAID (2014) Policy Monitoring resource guide
245 Measure Evaluation (2020) WHO’s short list of reproductive health indicators for global monitoring
78
10. Improve data sources • Population data for effective planning at the local level, budgeting and
informing policy, monitoring at the central level, and better targeting of left-behind
monitoring and population groups.
evaluating progress • The MPFS conducted every 10 years are too spaced out.
and frequency of • High priority: set strong indicators and monitoring system to regularly
collection assess progress.
11. Identify promising • Promote the scaling-up and institutionalising of good practices that
interventions and include integrated approaches to voluntary, human rights-based FP at the
support scale-up country level and do so in collaboration with other development
efforts. partners²⁴⁶.
• Policy change or adaptation to support and institutionalise scale-up
efforts.
12. Ensure that policies • Policies should be viewed as living documents to be regularly reviewed
and strategic plans are based on contextual changes and requiring leadership, resources,
periodically reviewed monitoring, and other inputs dimensions that influence policy
and kept up to date. implementation to thrive and achieve their goals²⁴⁷.
247 USAID (2010) Taking the Pulse of Policy: The Policy Implementation Assessment Tool Bhuyan, A., A. Jorgensen, and S. Sharma. 2010. Taking the Pulse of Policy:
The Policy Implementation Assessment Tool. Washington, DC: Futures Group, Health Policy Initiative.
79
APPENDIX 1:
Contextual Information Across Selected Muslim Countries
Commitments to key international conventions/ protocols relevant to reproductive rights and the
right to sexuality education Refer Table 4 from PART II
Contextual information across selected countries (2018 data mostly)248 Refer Table 5 from PART II
FP 2020’s Core Indicators Comparison Across Selected Countries
The FP 2020 Core indicators monitor FP progress across countries249 and cover FP based on a results
chain that aims to measure aspects of the enabling environment for FP, the service delivery process,
the service outputs, expected outcomes and the impact of contraceptive use. (see Table 7).
Table 7: Family Planning 2020’s Core Indicators 2019 To Monitor Progress Across Selected
Countries250
Core FP indicators Malaysia Turkey (N/A) Egypt Morocco (N/A) Bangladesh
1. Additional users (all -- -- 1.5 -- 2.847

women, millions)
2a. Modern contraceptive 38.3 -- 41.5 -- 46.3

prevalence rate (2017)²⁵¹
(mCPR), (% all women)
2b. mCPR, (% married -- -- 58.4 -- 56.6

women)
3. Unmet need for FP (% 19.6 -- 14.1 -- 18.9

married women) (2014)²⁵²
17.6
(2017)²⁵³

249 FP2020 Data Dashboard (2019) FP2020’s Core Indicators to monitor progress across countries
250 FP2020 Data Dashboard (2019) FP2020’s Core Indicators to monitor progress across countries
251 United Nations Department of Economic and Social Affairs (2017) World Family Planning
80
4. Demand satisfied (%) 58 -- 80.5 -- 75

(2016)²⁵⁴
54.7
(2017)²⁵⁵
5. Unintended -- -- 1.35 -- 4.22

pregnancies (millions)
6. Unintended -- -- 3.95 -- 7.68

pregnancies averted
(millions)
7. Unsafe abortions -- -- 1.6 -- 3.07

averted (millions)
8. Maternal deaths -- -- 1.3 -- 6.7

averted (thousands)
9. Method Mix (% married population)
Sterilisation (male) -- -- 0 -- 2.2
Sterilisation (male) -- -- 2.1 -- 8.5
IUD -- -- 52.9 -- 1.1
Implant -- -- 0.9 -- 3.2
Injectable -- -- 14.9 -- 23
Pill -- -- 28.1 -- 50.1
Condom (male) -- -- 0.9 -- 11.9

Lactation Amenorrhea Method -- -- 0 -- 0
Other methods -- -- 0.2 -- 0
10. Domestic government -- -- n/a -- 218,600,6000

FP expenditures (USD)
11. Couple-years protections -- -- n/a -- n/a
254 ARROW (2018) National Report: Malaysia – Child Marriage: Its Relationship with Religion, Culture and Patriarchy
81
12. Method Information -- -- 28.8 -- n/a

Index (%)
13. FP decision making (%) 89.2²⁵⁶ -- 98 -- 91.1
14. Adolescent birth rate -- -- 56 -- 113

(per 1000 women
15–19)
15. Discontinuation and -- -- -- -- --

method switching
256 Lembaga Penduduk and Pembangunan Keluarga Negara (LPPKN) World Population Day 2018
82
APPENDIX 2:
Family Planning Environments Across Selected Countries
Table 8: Family Planning Environments Across Selected Countries
Malaysia Turkey Egypt Morocco Bangladesh

Population and Related Family Planning Successes
• 1st FP policy Turkey’s successes258: Egypt’s successes259: Morocco’s successes261: • Since the 1st
statement in 1966 • Dramatic declines • NPS success is • TFR is 2.04 births population policy
coordinated by in TFR (from 5 in attributed to the per woman in in 1976, there has
NPFDB to improve the early 1970s to firm and effective urban areas and 2.8 been substantial
MCH and 2.6 in 1998) and political births per woman government
decelerate infant mortality rate determination to in rural areas. commitment in
population growth from 200 per 1,000 curb the population • Reproductive improving PHC via
rate from an annual live births in 1963 increase via health needs to community clinics
3% in 1966 to 2% to 35.3 in 2000. multisectoral be projected to in underserved
in 1985 by engagement increase along with communities265.
increasing FP (Ministries and women of • Achieved several
acceptors. FP was NGOs). reproductive age ICPD PoA goals,
integrated into the • Public sympathy from 8.5 to 10 reducing TFR from
primary health is critical to the million in 2010-25. 6.3 births in 1975
system and linked success of any • Morocco improved to 2.3 in 2017,
with reproductive strategy. The NPS reproductive knowledge of FP
health efforts257. will only succeed health, although method is near-
• Since then, if families started less than other universal among
impressive feats to think not only developing couples and
in human/ social in terms of what countries of similar increased CPR,
development. is good for them economic attributed to
but also of what development262. strong political
is good for their commitment and
country. implementation
of effective and
sustainable FP
programmes266.
12:116–127
259 UNFPA (2016) Egypt - Population Situation Analysis
261 UNFPA (2011) Final country programme document for Morocco 2012-16
262 Abdesslam B (2011) Social determinants of reproductive health in Morocco. African Journal of Reproductive Health
265 PMMU (2017) Program Implementation Report 2017 of the 4th Health, Population and Nutrition Sector Program (4th HPNSP)
83
Population and Related Family Planning Successes
• Under the National • Infant mortality • Progressive laws
Strategy, the Two decreased due and policies to
(2) (children) is to immunisation expand the rights
Enough inter- efforts, but of women and
ministerial maternal mortality young people267.
campaign is raising remained constant.
awareness to curb An efficient PHC is
population growth needed to reach
and accelerate health for all263.
social development Factors in fertility
among the poorest decline264:
governorates with • Due to increases in
the highest fertility women’s average
rates260. age at marriage,
married women’s
contraceptive use,
desire for smaller
families, and
increases in girl’s
educational level.
Demographic and related Family Planning challenges
Situational analysis Turkey’s challenges270: Egypt’s challenges271: Morocco’s challenges273: Bangladesh
on Population and • Early marriage • Unequal gender • While infant challenges277:
Family in Malaysia remains an issue power dynamics mortality decreased • Growing population
reports on the and affects lead to prevalent due to immunisation size and density.
population adolescent SRH harmful practices efforts, maternal • High proportion of
challenges268: with a higher risk of (FGM and early mortality remained pop <15 years.
• Declines in fertility obstetric marriage), affect constant during the • Low female age at
rates have complications. childbearing trends, last 15 years. An marriage.
accelerated • Traditionally, encourage large efficient PHC is • Early childbearing.
Malaysian’s ageing premarital sexual families, and needed if countries • High neonatal and
process with activity for women decrease demand like Morocco are to maternal mortality.
potential future is stigmatised and and use of FP reach the goal of • Extremely high
labour shortages condemned. services. health for all274. adolescent fertility
260 Wahish, N (2018) Family planning in Egypt: The ‘Two is enough’ project
264 Population Reference Bureau (2006) Fertility Decline and Reproductive Health in Morocco: New DHS Figures
267 UNFPA (2016) Bangladesh - Country programme document for Bangladesh 2017-20
270 Ozvaris SB, Akin L, Akin A (2004) The Role and Influence of Stakeholders and Donors on Reproductive Health Services in Turkey. Reproductive Health Matters 12:116–127
271 United Nations Population Fund Country programme document for Egypt (2018–2022)
84
Demographic and related Family Planning challenges
impacting the • Perinatal mortality • Major regional • Health indicators Contextual issues278:
economy. High rate is still high at disparities in access improving but wide • Reached the lower
productivity should 42 per 1,000 total to -and provision spatial disparities middle-income
drive economic births, indicating a of- adequate FP persist, particularly country group in
growth, with need for improving services. Poverty in rural areas275: 2014, although
interventions to maternal health. and rural settings Morocco’s challenges276: 23% of the
stop the fertility • Marked differences associated with • Improving health population still live
decline. in regional and high fertility and indicators but below the poverty
• Challenges to have rural vs urban low contraceptive SRH inequalities line.
more children: indicators prevalence. between urban and • Differential
financial (65%); attributed to • High fertility rural, rich and poor, development
late marriage (the gender differences rates since 2006, developed and across rich/ poor,
late 20s); difficulty in educational reaching 3.5 birth deprived regions. urban/ rural
to find a spouse levels: 19% of per woman in 2014 • During the last districts.
(18% ;36 ) and all women were and decreasing to decades, fertility • Insufficient
37%subfertility. illiterate in 2000, 3.1 in 2018272. declined due to allocation of
• Multi-ethnic/ particularly in rural different parameters. resources for
multi-faith society areas. Infant mortality Health System
with different FP • PHC services, decreased and (64% out-of-
needs-a challenge including should reach the pocket payments).
to cater to each reproductive health SDG, whereas • Challenging
group269. and FP are limited maternal mortality implementation of
• Malaysia had the in disadvantaged has remained progressive policies
lowest CPR and neighbourhoods. constant. due to inefficiencies
highest unmet in government
need for FP across mechanisms and
countries, partly weak systems and
because SRH institutions for
services not equity-based
properly promoted, planning, budgeting,
and adolescents coordination and
might be afraid to monitoring. The 4th
access them for HPNSP includes
fear of being specific indicators
stigmatised or to address the
discriminated challenges279.
against.
272 UNFPA (2020) Egypt Family Planning.
279 UNFPA (2016) Bangladesh - Country programme document for Bangladesh 2017-20
85
Legal Frameworks (Child Marriage, Abortion, GBV, FGM)
• 1966 Population Turkey’s legal Three (3) stages of the • Commits to FP/ SRH Contextual issues293:
and Family framework282: population policy are rights286. • Bangladesh’s
Development Act • 1st anti-natalist identified284: • 2004 Moroccan commitment and
352280. Population Planning • 1st stage from 1962 Family Code response to FP are
• Civil laws apply Law in 1965, when the Egyptian (Moudawana)287 of based on human
to Muslims and legalising government Maliki Sunni Islamic rights principles
non-Muslims, contraception adopted a fertility school, regulates and aligned with
except for family information and reduction policy. family (marriage, the international
(Syariah) laws, services. Surgical • 2nd stage from polygamy, divorce, frameworks on
covering incest, sterilisation and 1973 with a inheritance, child Child Rights
marriage, divorce, abortion permitted socio-economic custody), praised Convention, ICPD
children’s custody only on eugenic and approach to for addressing PoA, the Beijing
& division of assets medical grounds. fertility reduction, women’s rights & Platform for Action
Muslims divorces, Unsafe abortion considering the gender equality in and the SDGs.
applied in a was an unreported socio-economic Islamic law288. • The strategy also
religious (Syariah) problem. standard of the • 2011 constitution aligns to the
Court281. • 2nd Population family; education; notes equality in Constitution, which
• Malaysia is a Planning Law of women’s status; health care access guarantees the
member of the 1983 authorised mechanisation of and services & right to health
UN Human Rights mid-level providers agriculture; equity in the spatial care and medical
Council and signatory to insert IUDs, industrialisation; distribution of treatment for all its
to the following legalised induced infant mortality resources289. citizens, irrespective
conventions, albeit abortion up to 10 reduction; social • Improvements of of age, sex, caste,
with reservations: weeks pregnancy security; IEC; and the FP programmes creed and colour.
CRC; Convention on and licensed GPs FP services. since the 1960s. • The strategy is
the Rights of Persons for TOP. • 3rd stage from CPR increased from guided by a
with Disabilities • The current political 1975 with a 19% in the 1980s number of legislations
(CRPD); and environment is developmental to 63% in 2003, including the
Convention on the pronatalist and approach to Egypt’s and 54.8% modern Children Act 2013,
method290.
280 Laws Of Malaysia (1966) Malaysia Population and Family Development Act 1966
281 Hazariah A, Fallon D, Callery P (2020) An Overview of Adolescents Sexual and Reproductive Health Services Provision in Malaysia. Comprehensive Child
& Adolescent Nursing.
12:116–127
284 Hassan AS (1984) The population policy in Egypt: a case in public policy analysis. Dirasat Sukkaniyah 11:[3-15], 19-25
287 Center for Public Impact (2020) Reforming Moroccan family law: the Moudawana. Centre for Public Impact (CPI).
288 Boutayeb W, Lamlili M, Maamri A, et al (2016) Actions on social determinants and interventions in primary health to improve mother and child health and health
equity in Morocco. International Journal for Equity in Health
86
Legal Frameworks (Child Marriage, Abortion, GBV, FGM)
Elimination of All antiabortion283: population problem • Family law reform, Women and Children
Forms of Discrimination the government (Strategy of National but 50% of women Repression
Against Women proposed in 2012 Development 1978- are required to be Prevention Act
(CEDAW). Malaysian to restrict abortion 82) considering the accompanied on 2000 (amended in
reservations to via a bill not impact of population medical 2003), Human
certain CEDAW passed. Women size, distribution consultations291. Trafficking
articles regarding report difficulties and characteristics • Abortion only legal Prevention and
women’s rights accessing abortion. on the level of for mother’s health, Deterrence Act
relating to marriage • Progressive gender welfare285. fetal abnormalities, 2012, and the Child
and family relations, equality laws, but rape or incest. Marriage Restraint
including child patriarchal structures. Estimate 600-800 Act 1929 (amended
marriage. Education influence conducted daily by in 1983).
health services doctors and 200
utilisation. illegally292.
Related Strategies
• 2nd Malaysian • Turkey issued a • NPS 2015-30 Morocco Public • 4th Health,
Population National Strategic developed by an health302: Population and
Strategic Plan Action Plan for inter-ministerial • Maternal Mortality Nutrition Sector
Study (2010); The SRH 2005-15295, group coordinated Surveillance Program (4th
National Strategy although the sexual by the NPC298,299. System indicated HPNSP) 2017-
on HIV and AIDS for health policy trend • Supporting the NPS: 80 % of 2009 22305, led by the
2011-2015; and is shifting away Child Strategy, Early maternal deaths Ministry of Health
Revised 2010-15 from its previous Marriage Strategy avoidable by and Family Welfare.
National Policy for commitment to and Egypt Sustainable increasing the • National Plan for
Older Persons. a rights-based Development Strategy standard of care in Sexual and
• Situational analysis approach. While (Egypt’s Vision)300. hospitals303. Reproductive
on Population and Turkey has made • FP from the • The Maternal Health, A costed,
Family in Malaysia294 marked progress religious Mortality Strategy integrated national
298 UNFPA (2017) Population Situation Analysis Egypt 2016 Report
299 UNFPA (2016) Egypt Population Matters
300 Egypt Ministry of Planning, Monitoring and Administrative Reform (2016) Sustainable Development Strategy: Egypt Vision 2030
302 European Committee of the Regions (2020) Morocco Public Health
87
Related Strategies
reports on the in FP to date296, perspective: the action plan of plan which prioritises
population access to SRH individual family 2008–12 to reduce access for key
challenges and services has level involving its the maternal groups.
proposes strategies become more social, economic, mortality rate • 5-yearly plans
for population limited in the last and health (MMR) from 227 aligned with ICPD
development five years due to conditions or to 50 deaths per and SDG objectives
programmes via 40 the conservative society level, while 100,000 births. to address reproductive
recommendations political environment. birth control is Strategies: health and rights,
to address objectives Since 2007, the viewed as a public i. reduce barriers youth development,
and targets under government’s policy adopted and preventing women and gender equality
each pillar to be pronatalist population enforced by the from accessing challenges.
implemented planning within the state. The population emergency services; • Supporting the 4th
across ministries most recent Four-Year policy failed to ii. enhance health HPNSP: National
and agencies Development distinguish between care quality; and Strategy for
during 2018-30. Plan297 encourages these two (2) levels. iii. to improve Adolescent Health
women to bear a • Population policies governance. MoH 2017-30306.
minimum of three were made and 2019 data from
(3) children. approved by the maternal mortality
Supreme Council surveillance system
for Population and revealed that MMR
Family Planning301 reduction to 50
not achievable by
2015. Thus, new
action plan 2012-
16 introduced to
target actions for
rural and
disadvantaged
areas304.
306 Bangladesh Directorate General of Family Planning (2016) National Strategy for Adolescent Health 2017-2030
88
\ Institutional Mechanisms for Family Planning
• The National Institutional • A 2013 National Commits to FP and • The Population
Population and mechanisms308: Population and SRH health312: Council is supporting
Family Development • The General Development • Improved trends. coordination and
Board (NPFDB) Directorate of Conference National FP accountability:
established to plan MCH-FP set up in resulted in the programme since • Post ICPD, it formed
and coordinate all 1965 within the establishment of 1966, established a a National Committee
FP activities in the MoH, develops an inter-ministerial national population and Developed a
country, beginning policies and strategies, group coordinated commission and National PoA
with clinical implements by the NPC tasked local population for implementation
contraceptive programmes via with developing the commissions. of ICPD PoA and
services in urban FP health centres NPS 2015-2030. Repeal 1967 formulated national
areas and expanding and evaluates MCH • The NPS has a French Law that is policies on Population,
to rural areas via and FP programmes multisectoral prohibiting Maternal Health,
integration of FP nationally309. approach to contraceptives. HIV/ AIDS and STD
with PHC services • The Women’s ensure integration • In the 1990s, SRHR and Population,
of MoH in the early Health and Family of services and issues gained Health & SRH and
1970s307. Planning Advisory efforts including political attention Nutrition313.
• FP services are Board established government, private with advocating
conducted through and chaired by sector, public and NGOs. Ministry for
a multisectoral MoH in 1993 private media Economic Forecasting
approach across reports to Minister institutions, and Planning mandate
implementing via MCH–FP. volunteers and (along with the 16
agencies with Membership NGOs311. regional commissions)
NPFDB acts as includes MoE, to ensure integration
coordinator; FP Labour, Media, of population concerns
service delivery is Religious Affairs, into development
based on aspects Universities, the planning.
of health and Army, NGOs, civil • End of the 1990s,
family’s health, society and other impressive gains in
and the practice is sectors310. FP, MCH. In 2003,
voluntary. • The Board motivates MoH purchased
all sectors to initiate contraceptives
new approaches without donor
and programmes contribution.
12:116–127
12:116–127
310 European Committee of the Regions (2020) Turkey Public Health
312 Population Reference Bureau (2006) Fertility Decline and Reproductive Health in Morocco: New DHS Figures
89
Institutional Mechanisms for Family Planning
based on ICPD Narrowed gap in
recommendations FP service delivery
(launched education in rural and poor
for adolescents areas to meet
on SRH in schools rising SRH services
and education for & contraception
soldiers to improve demand. In 2004,
male involvement >50% married
in fertility regulation women in rural
and FP). areas using modern
FP method.
Family Planning Strategy and Costed Implementation Plans
(multi-year actionable roadmap designed to help the government achieve its FP goals)
• No FP Policy Turkey’s resources314: • EU316 is supporting • The 2020-25 Costed Implementation
endorsed, but 1966 • Comprehensive FP the design of a National Reproduc- Plan (CIP) for 2020-
operational policy programme since multisectoral FP tive Health Strat- 2022 National
statement for 1965 successfully National Costed egy has several Family Planning
implementing improving modern Implementation strategic principles Program in
national FP contraceptive use. Plan 2019-23 led noted below319. Bangladesh320:
programme. • Turkey issued a by MoHP to identify identifies key
1. Malaysia reduced National Strategic gaps in program- strategies and
the TFR to 2.0 Action Plan for SRH ming, agree on activities for
births per couple, 2005-2015315. interventions and achieving the goals
and a further TFR • The 1995 Women’s estimate cost317. costed for three (3)
reduction will Health and Family • UNFPA and MoHP’s years (2020-2022 of
impact Malaysia’s Planning Strategic Family Planning current 4th HPNSP)
future economic Plan was developed and Reproductive including:
growth. Thus, by government Health Sector • Strengthening
although it is and NGOs, led 10th Country service delivery
important to increase by MCH–FP with Programme Action provision in
the CPR, this should UNFPA’s financial Plan (2018-2022)318 existing facilities
be balanced to support, focused to universal access (service coverage,
avoid a further TFR on strengthening to SRH services by current and new FP
decline by targeting inter-sectoral targeting selected commodities, and
12:116–127
315 Yilmaz V, Willis P (2020) Challenges to a Rights-Based Approach in Sexual Health Policy: A Comparative Study of Turkey and England. Societies 10:33. https://doi.
org/10.3390/soc10020033
316 European Union, Egypt Ministry of Health and Population and UNFPA (2019) EU Support to Egypt’s National Population Strategy
90
Family Planning Strategy and Costed Implementation Plans
(multi-year actionable roadmap designed to help the government achieve its FP goals)
contraception collaboration and governorates with human resources).
awareness and the SRH components the poorest SRH • Increasing
services to address of PHC units to indicators. acceptability of
unmet needs. reduce regional long-acting reversible
2. Increased awareness differences in contraception and
of contraception health indicators. permanent methods
among those high Shared reproductive through skilled human
risk for STDs to health and FP resources and male
reduce HIV infection services costs (but engagement.
rates. limited budget): • Promoting interval
3. Education and • MCH-FP pays for and postpartum
awareness among FP commodities contraception.
primary care (contraceptives, • Intra-and inter-
providers regarding equipment and sectoral collaboration
contraception for educational and coordination,
women with an materials). including NGOs.
unstable medical • MoH pays for • Special focus on
condition. personnel, hard to reach and
maintenance and urban areas, and
clinic buildings. other low performing
areas.
• Monitoring, Evaluation
and Research.
• Targeting adolescents
and youth, particularly
males.
Vision, Mission, Goals and Development Objectives
• Fertility policy • FP policy trend • NPS 2015-30328: • The 2020-25 Reduce population
shifted from shifting from its i. Reduce population National growth rates and
decreasing TFR to previous growth rates and Reproductive birth rate:
no intervention and commitment to birth rate from 3.5 Health Strategy • 4th HPNSP332
raising population a rights-based births per woman has several strategic Vision: to produce
quality via education approach323. to 2.4 by 2030 and principles: healthier, happier
and human resource • The current political scale up FP institutional and economically
development321. environment is programmes coordination and productive
• Current direction: pronatalist and (increase CPR from evaluation; population and
91
address fertility antiabortion324: 59% to 72%) to increasing access achieve the middle-
decline (subfertility; Turkey issued a simultaneously to SRH services for income country
pro-fertility incentives; National Strategic address poverty targeted populations; status by 2021.
childcare options). Action Plan for and population integrate a monitoring
• Situational SRH 2005-2015325, growth329 while and evaluation Mission:
analysis on although the sexual targeting system; strengthening create opportunities
Population and health policy trend disadvantaged SRH partnerships to reach and maintain
Family in Malaysia322 is shifting away governorates and and research. The optimal health.
i. Pillars: from its previous empowering women. focused areas
addressing fertility commitment to ii. Improving population include: adolescents’ Goal:
decline (address a rights-based characteristics330, SRH, physical and ensure citizens
subfertility; pro- approach. While Pillars: improve the mental health enjoy health and
fertility incentives; Turkey has made population’s quality Including STIs; well-being by
childcare options); marked progress of life via: FP; (re-designing expanding access
ii. strengthening in FP to date326, • strengthening premarital to quality and
family institution access to SRH access to FP and consultation), equitable health
(promote parental services has SRH; maternal health; care in a healthy
skills, family become more • foster youth perinatal care; environment.
cohesion and limited in the last development; addressing
intergenerational five years due to • advance girl’s violence towards Development
support systems); the conservative education and women and objective:
iii. enhancing political environment. women’s children; uterine, increasing access to
population resiliency Since 2007, the economic cervical and breast quality healthcare
(raise productivity, government’s empowerment; cancer prevention; and improvement
LFP for , pronatalist • deploy mass infertility treatment; in equity along with
flexible working population planning media awareness and health issues achieving UHC.
arrangements, within the most raising campaigns related to
life-course recent Four-Year to support all of menopause331.
approach to Development the above.
improving health, Plan327 encourages • FP objectives under
expand family- women to bear a the NPS:
centric programmes); minimum of three more effective FP

325 Yilmaz V, Willis P (2020) Challenges to a Rights-Based Approach in Sexual Health Policy: A Comparative Study of Turkey and England. Societies 10:33. https://doi.
org/10.3390/soc10020033
330 NPC, Embassy of Switzerland in Egypt, and UNFPA (2019) Review of the Executive Plan 2015–2020 In the Context of the National Population and Development
Strategy 2015–2020
92
iv. mainstreaming (3) children. and perinatal health
policies for active services; improved
ageing; and health services to
v. enabling inclusive youth; enhancing
progress for all. population
characteristics;
raising awareness of
population problem;
women empowerment;
and monitoring and
assessment efforts.
Key Partners in Delivering Family Planning Services
• NPFDB, MoH, and • The Turkish Family • The EFPA (Egyptian • The Moroccan The Population
FRHAM333. Planning Association, Family Planning Association to Council.
The private sector an NGO founded Association)335 combat Clandestine
involved in FP in 1963, the Family coordinates the Abortion (AMLAC).
commodities needs Health and Planning delivery of FP
to be more engaged. Foundation, universities services via voluntary
and the MoH have organisations; a
collaborated with lead partner in the
the international National Population
agencies to provide Commission’s
reproductive health initiative to increase
programmes and contraceptive
services334. prevalence across
the country.
• EFPA provides IEC
programmes for
the general public,
particularly amongst
young people, are
run on a peer-to-
peer basis. Emergency
intervention to
prevent reported
early marriage cases.
12:116–127
335 C van W, F A, T F, et al (2017) Primary health care policy implementation in the Eastern Mediterranean region: Experiences of six countries. Eur J Gen Pract 24:39–44.
93
Integration of FP Services Into Primary Health Care (PHC) is essential for equitable access and
cost-effective health care and a key factor in the global strategy for universal health coverage (UHC)335:
• The National No information was Integration FP Integration FP No information was
Programme makes found. services into PHC340: services into PHC341: found.
FP services and • 92.1 million population • Lower middle-
information available with 28.3 physicians income country
via a network of per 10,000 inhabitants. with 34 million
clinics. MoH • PHC was established people and has
integrates FP in the early 1940s 0.68 physicians per
services with the based on general 10 000 population.
rural health services, practice and maternity • The public sector,
while NPFDB, and child health Royal Armed Forces,
FRHAM and private services by the private sector, and
sectors provide mid-1990s. informal sectors
for FP in urban • There are provide PHC services.
areas336. Private approximately • The public sector
hospitals/ clinics 5314 PHC facilities is responsible for
and commercial with 14,973 GPs two (2) levels of
outlets also provide and 256 certified delivery: 1. health
FP services. FPs. Of these centres, overseen
FP services facilities, 61% by a GP and a
• All government implemented an FP nurse, provides
health and MCH approach based on health promotion,
clinics provide FP formal accreditation. preventive, and
Services. MoH Three (3) types curative care; 2.
hospitals offer of facilities are in health centres
limited FP Services. operation: family including emergency,
• In 2019, MoH health units, family oral, and mental
reported 1,000 health centres, and health services.
Health Clinics and district hospitals; • The private sector
90 MCH Clinics; with a PHC facility provides PHC
1,791 Community within less than service via medical
Clinics, 217 Mobile 5 km for 95% of practices, run by
Health Clinics, and the population. individuals or
4 Flying Doctor This has resulted GP group. Has
teams with 4 in nearly 91% advanced health
helicopters337. of children aged system to address
• FRHAM delivers 18–29 months fully inequities in services
a service range vaccinated. provision.
337 Ministry of Health (2019) Health Facts 2019 Translated from Malay
340 C van W, F A, T F, et al (2017) Primary health care policy implementation in the Eastern Mediterranean region: Experiences of six countries. Eur J Gen Pract 24:39–44.
341 N N, R H, Am AD, et al (2019) Primary care health care policy implementation in the Eastern Mediterranean region; experiences of six countries: Part II. Eur J Gen
Pract 26:1–6.
94
Integration of FP Services Into Primary Health Care (PHC) is essential for equitable access and
cost-effective health care and a key factor in the global strategy for universal health coverage (UHC)335:
via 39 permanent • The government • The advent of
clinics, 356 mobile has created a mandatory medical
facilities & 205 four-year FP coverage has been
community-based fellowship training a real social evolution,
distributors/ programme, while obligating the state
community-based various universities to implement the
services338. did shape a regulation of health
• NPFDB’s SRH postgraduate five- care providers and
services have been year training control costs in the
expanded in recent programme. The private and public
years via 49 clinics main challenges sectors.
across the country are the high out-of- • Challenges include
delivering pocket barriers in services
contraceptive safe expenditure on access due to
effective, affordable health, low geographical
and acceptable government concentration and
choices. spending and poor both qualitative
Fertility services are government vision and quantitative
limited to: on family practice, deficit in health
• 3 fertility clinics resulting in poor professionals, as no
(NPFDB, 2020). public health specialised training
• 135 clinics and 1 services that force for family medicine
hospital with most of the poorest is available. The
fertility facilities339. to use private two-year master’s
While all MoH health care. degree programme
hospitals have in Family and
fertility clinics, Community Health
services might not developed in 2015
be consistently is not a substitution
provided. for the urgent need
to scale up family
medicine training.
338 International Planned Parenthood Federation (2020) Federation of Reproductive Health Associations, Malaysia (FRHAM)
95
• Programmatic achievements (should be measured by indicators)
• NPFDB collaborates The FP programme NPS progress review Morocco’s • Of the 131 indicators
with MoH and has344: – Year 2345: achievements346: used, 31 (24%)
FRHAM in providing • Improved quality Outcome 1: FP • Launched in 2008, have been fully
FP and other of care and service services including the national plan achieved, and 18
reproductive health utilisation and contraceptive for accelerating the (14%) are partially
services to the expanded the range scaled-up and more reduction of achieved in the first
community342. of SRH services in accessible (supply- maternal and progress report.
• MoH’s 2019 MCH high demand areas. side) by enhancing neonatal mortality • The 4th HPNSP
Attendances343: • Reduced unmet the supply chain, has improved focused on improving
Antenatal need for FP building service access to—and the HR capacity via
Attendances and increased providers capacity quality of— training workshops,
6,219 ,159 contraceptive and integrating FP obstetrical and seminars and
Postnatal choice by introducing and youth-friendly neonatal care. orientations, which
Attendances implants & services into primary • Although access has been conducted
496,640 injectables. he PHC healthcare to health care for 31,682
Child Attendances • Distributed National centres via cross- and services and participants349.
9,938,375 Service Guidelines sectoral training & health outcomes
on FP to all PHC integrating FP services improved,
units in 1994. into routine socio-economic
• Involved men in immunisation services inequalities and
FP and STI care by in postpartum. special health
Turkish Family inequity are
Planning Foundation Outcome 2: Youth persistent (urban
via IEC SRH & reproductive age vs rural)347 use. In
programmes for population educated Morocco, 1992-
young men doing on FP, smaller family 1995 changes
compulsory military value, SRH and GBV in the FP supply
service -particularly via sports festivals environment, in
important in a (demand-side), particular, the
male-dominated targeting governorates increased presence
society-which were with highest fertility of nurses trained in
scaled up. & poverty via NGOs FP at public clinics,
• Launched safe door-to-door visits played a significant
motherhood and training religious role in the increased
342 Ministry of Women Family and Community Development, Lembaga Penduduk Dan Pembangunan Keluarga Negara
12:116–127
96
Programmatic achievements (should be measured by indicators)
initiatives in 8 pilot /community leaders use of modern
provinces by NGOs across religions contraceptives
with UNFPA & (Muslim, Christian) during the study
UNICEF. on FP. period.
• Improved FP However, programme
counselling services. Outcome 3: efforts to broaden
• Improved FP in Strengthened the mix of
undergraduate institutional contraceptive
medical and capacities for methods used by
nursing–midwifery monitoring and Moroccan women were
school curricula in coordination of NPS less successful348.
1992-98 by MoH. implementation via
an intra-ministerial
Steering Committee.
Key implementation challenges
• Malaysia had the Challenges in the • Population Morocco’s From the first progress
lowest CPR and provision of Situation Analysis352: challenges353: report356:
highest unmet reproductive health the NPS review • The achievements • Delayed receipt of
need for FP across and FP services351: shows that accomplished in fund hindered the
countries, despite • Poor intersectoral objectives adopted reproductive health implementation of
contraception collaboration in the planning remain insufficient. planned activities.
services being between MoH phases were not FP and contraception • Insufficient fund
integrated into PHC units. MoH should achieved due to the policies need to allocation.
and made available establish a lack of resources, reach more women; • Unavailability of a
for all youth and Coordinating weak coordination, and antenatal and robust system for
women at government Committee on discontinuity of postnatal care monitoring and
clinics, partly Population and institutional should be enhanced, supervision.
attributed to the Reproductive framework, especially in rural • Issues with HR,
fact that SRH services Health to plan, centralisation, and areas and deprived including storage,
are not properly coordinate and the absence of regions. retention and
promoted, and collaborate on monitoring and • FP and contraception vacancy in the
adolescents might relevant reproductive evaluation. policies need to sanctioned position.
be afraid to access health and FP reach more women;
them for fear of activities. antenatal and
being stigmatised • Complex bureaucratic postnatal care
or discriminated procedures for should be enhanced,
348 Hotchkiss DR (1998) Family Planning Program Effects on Contraceptive

12:116–127
97
• Key implementation challenges
against. budget expenditure, and more skilled
• Need to expand the causing delays in medical personnel
country programme supplies. are needed to assist
core areas of young • High turnover women during
people’s SRHR, among health labour, in rural
empowerment personnel needing areas and deprived
of marginalised regular training by regions354.
women, protection the MoH. Morocco’s FP355:
from gender-based • Unbalanced • In 2003, about
violence, ensuring distribution of 10% of women
the quality of life health personnel aged 15-49 years
for the elderly as across the country had an unmet need.
well as revitalising (rural and urban Feedback studies
the national FP and western and indicate the possibility
programme, and eastern regions). to improve the
include new and • While the MoH, efficiency of
emerging issues supported by these services,
such as migrant international donors through vertical
workers and the and national NGOs programmes, by
feminisation of piloted several more integrated
HIV/ AIDS350. successful reproductive and comprehensive
health programmes, ones.
most pilots were • The FP programme
not replicated due required quantitative
to lack of political and qualitative
commitment and improvements
mismanagement. regarding % of
women using
contraception
(63%), diversification
of contraceptive
methods and
reduction of
unplanned
pregnancies.
350 UNFPA (2013) Country programme document for Malaysia 2013-17

98
Issues Needing Attention
• The contraceptive • The current political • Population • SRH in Morocco From the first
prevalence rate environment is Situation Analysis360: can be improved progress report:
increased to 52 % pronatalist and Though being by adopting targeted • Off-track indicators
in 1984, fertility antiabortion358. multi-faceted and and equitable include MMR,
has been declining, Thus advocacy to comprehensive, the health strategies Neonatal Mortality
reaching replacement prioritise reproductive NPS overlooked that aim to enhance Rate, TFR, unmet
level, attributed to health services, significant factors: the mean status of need for FP, PNC
rising age at marriage and abortion care i. the strategy and its the whole population coverage and IYCF
and increased in the public health plan omitted but at the same practices that need
contraceptive system is needed. investment in a time to reduce to be adequately
use357. • Turkey’s centralised large number of regional disparities addressed.
health governance young people (1/3 between developed • Need for improved
makes its sexual of the population). and disadvantaged institutional
health policies ii. despite a large regions; inequalities coordination
vulnerable to number of political between rich and between health,
abrupt and parties in Egypt, the poor, and nutrition and
immediate changes strategy did not marginalisation of population services
—as demonstrated involve these the rural population361. to avoid duplication,
by the conservative parties to any extent. training, nursing
political turn that iii. more data needed services, quality
began in the early to monitor the NSP assurance, and
2010s359. implementation. availability of HR at
the facilities362.
• Indicators that
are related to RH
and fertility are
driven from surveys
conducted with
wide time spaces
and had sample
sizes disallowing
the calculation of
indicators at small
administrative units
level.

99
•
Data sources informing policy, monitoring and evaluating progress, and frequency of collection
• MPFS conducted • 5-yearly DHS since • 2014 Demographic • Morocco National • 6-yearly Population
every 10 years 1963 to monitor and Health Survey. Survey on Population and Housing
since 1974 (the health trends. Egypt Population, and Family Health Census informs
latest survey was Housing, and 2010-2011: a socio-economic
the 2014 5th Establishments nationally development
MFFS-5363, Census 2017364. representative planning and policy
stratified and • Survey of Young cross-sectional formulation at
representative of People in Egypt household survey366. national and sub-
the population). (SYPE)365, longitudinal national levels.
nationally • The demographic
epresentative and health data
survey follows up from the Bangladesh
youth in 2009, Demographic and
2014 and 2016 Health Survey
collecting gender- 2017-18 by the
disaggregated National Institute
information on SRH, of Population
health, schooling Research and
and employment. Training (NIPORT) is
Informs policies essential to monitor
and programmes the progress of the
for youth. 4th HPNSP 2017-
22367.
• Multiple indicators
from other clusters’
surveys.
364 Central Agency for Public Mobilization and Statistics (CAPMAS, Egypt) (2017) Egypt Population, Housing, and Establishments Census 2017
365 Population Council (2014) Survey of Young People in Egypt
366 Ministry of Public Health (Morocco) (2011) Morocco National Survey on Population and Family Health 2010-2011
http://ghdx.healthdata.org/organizations/ministry-health-morocco
367 NIPORT (2019) Bangladesh Demographic and Health Survey (BDHS) 2017-18: Key Indicators Report.
100
• For MoH, a Lessons learned368: National Population • Limited financial • The 4th HPNSP
monitoring • Turkey has and Development resources and the progress report
mechanism is strengthened Strategy 2015-30, varying levels of highlights
currently in FP policies and Review of the Executive political support. implementation
place at national, programmes over Plan 2015-2020369 challenges to
subnational and the years since and Population course-correct
facility level. For 1965 with support Situation Analysis370: programmes372.
MoH, the public is from international • Limited M&E, • Annual Program
most welcomed to donors, reaching suggest a Implementation
complaint using the several reproductive population Report 2018 of the
existing web-based health goals. observatory to 4th Health, Population
platform. • Although considerable monitor & evaluate and Nutrition Sector
progress has been NPS implementation: Program (4th
made, the agenda i. Collect and HPNSP).
remains unfinished. harmonise available
ICPD introduced data and indicators.
the concept of a ii. Assess and bridge
comprehensive information gaps
life-cycle approach, by surveys or
which is well innovative research
accepted in Turkey. (crowdsourcing/ big
• Involve men in FP data methodologies).
programmes. • Improvements
to SRH statistics
driven by the EFPA
via service delivery
(complementing
government
services)371.
12:116–127
369 UNFPA (2020) Review of the Executive Plan 2015-2020 in the Context of the National Population and Development Strategy 2015-2030
371 IPPF (2016) Egyptian Family Planning Association.
101
APPENDIX 3:
Recommendations from Malaysia’s 2010 Population Strategic
Plan Study
Table 9: Family Planning Related Objectives and Recommendations from Malaysia’s 2010
Population Strategic Plan Study373
Background Objectives Recommendations

Fertility Decline and Long-term Population Growth Objectives
• Need to address fertility • Sustain fertility at Suggested policies making childbearing more compatible
decline and avoid workforce replacement level in the with raising a family include:
contraction and rapid ageing longer term while • Introducing a period of paid paternity leave to make
population in FP policy and supporting couples clear the government’s support for gender balance in
labour market policy. (women and men) to child-rearing;
combine participation in • Providing for paid compassionate leave in cases of
• High % of university-educated the labour market and children’s sickness;
women remain single in their their family building. • Allowing more flexible working hours;
30s, and those married have • Provision of child-minding facilities at the workplace
low fertility. High opportunity and providing government subsidies for childcare
costs of leaving the workforce costs incurred by working mothers;
to raise children: policy to • Increasing tax concessions for dependent children;
facilitate their work-life • Programmes to encourage husbands to be more fully
balance. involved in child-rearing and household activities;
and
• Ethnic differentials in fertility • Fully meet the unmet need for contraception,
(Chinese and Indian populations especially among disadvantaged groups as failure
already below-replacement) to meet their contraceptive needs will place further
shifted population ethnic barriers on their families’ socio-economic progress.
composition with Malay
population driving fertility rates.
102
Background Objectives Recommendations
Reproductive Health
• Access to FP information and • Reduce the unmet need • Programmes to reduce unmet need for FP should
services is a basic right to for FP (as a matter of focus on: husbands who are apathetic or object to
enable couples to make their individual choice); FP; marginalised groups lacking knowledge of and
own choices about the births access to FP; users of traditional methods, and those
number and spacing. • Improve reproductive with religious concerns over certain methods; and
foreign workers.
health of adolescents
• Unmet need for the termination and the unmarried;
• Improve SRH of adolescents and older unmarried:
of childbearing in Malaysia
provide adolescents information and guidance in
is estimated to range from • Reduce resort to abortion, SRH matters, including STDs and sexual abuse (via
30-50% if unmet need for including unsafe abor- schools); instil a strong moral/ religious foundation
spacing is included. tion; and in children; review and where appropriate, remove
legal, regulatory and social barriers to SRH
• This has significant welfare • Support initiatives to information and services adolescents; identify
implications, given unwanted combat the spread of adolescents’ special needs and design programmes
children are unlikely to receive HIV/ AIDS and other to address those needs; develop programmes for
loving care from parents as STDs. prevention and treatment of sexual abuse and incest;
wanted children. provide sexually active adolescents targeted FP
information, counselling and services; provide pregnant
adolescents with support community support
• Infertility is a concern for
(scaled-up NPFDB’s Kafe@TEEN programmes); and
couples’ stability and might involve adolescents in the planning, implementation
cause emotional suffering. and evaluation of SRH programmes.
• Unmarried sexually active • Reduce resort to abortion, including unsafe abortion:

youth risk unwanted pregnancies, strengthen FP IEC programme; develop clear guidelines
unsafe abortion, and contracting and understanding of abortion law and policy;
STDs, including HIV/ AIDS. increase access to quality services for abortion
They require Comprehensive complications; and o train doctors in modern abortion
Sexuality Education and access techniques (equipped Hospitals/ clinics with appropriate
to FP services. equipment and supplies).
• Support initiatives to reduce HIV/ AIDS and other

STDs transmission: conduct studies on the pathways
of heterosexual transmission of HIV infection to
target programmes and interventions; use a
multisectoral approach for a coordinated response
to the epidemic involving MoH, some NGOs and
Community-Based Organisation; and develop
programmes that address SRH youth issues supported
by clear and coherent policies concerning SRH rights,
such as safer sex promotion and condoms use.
• Increase availability and affordability of infertility

treatment for those requiring such services and
study success of infertility treatment.
103
APPENDIX 4:
Country Comparison using Family Planning Effort and National
Composite Index on Family Planning
Table 10: Country comparison using the Family Planning Effort374
Family Planning Indexes Malaysia Turkey Egypt Morocco Bangladesh

2014 Family Planning Effort Index (FPE)
Total score 63.2 38.5 50.1 61.5 65.9
Policies 59.5 38.6 53.5 70.1 72.7
Policy on Fertility 45 14.6 44.4 42.1 84.9
Favorable Statement by Leaders
52 14 25.4 60.3 67.5
(1-2 times per year)
Policy on age at Marriage 62.6 27.4 74.6 75.4 69.8
Import Laws and Legal regulations 59.3 64.6 47.6 88.9 83.3
Advertising of Contraceptives 46.9 51.1 69 78.6 87.3
Objectives (Justifications)
Reduce Population Growth (pro vs antinatalist
26.3 20.7 81.7 36.5 88.1
FP policies)
Enhance Economic Development 69 40 73 72.2 67.5
Avoid Unwanted Births 86.5 75.7 83.3 86.5 84.9
Improve Women’s Health 88.9 72.2 84.9 90.5 81.7
Improve Child Health 88.9 63.9 73 88.9 81.7
Reduce Unmarried Adolescent Childbearing 56.7 37.8 14.5 31 48.7
Reduce unmet Need for Contraceptives 83 50 73 88.9 83.3
104
Services 60.3 30.3 49.8 59.6 60.9
Involvement of Private Sector Agencies and
64.3 38.2 39.7 65.9 55.6
Groups
Involvement of CIvil Bureaucracy 67.8 34.7 50.8 79.4 64.3
Community-based distribution 55 23.8 41.9 58.7 84.9
Postpartum Programs 70.8 33.3 56.3 68.3 38.9
Home visiting Workers 48.4 20.1 73 39.7 53.2
Administrative Structure 64.9 32.6 57.3 69 73.8
Training Programme 73.7 60.7 56.3 72.2 61.9
Personnel Undertaking Assigned Tasks 74.3 43.8 54.7 67.5 48.4
Logistics and Transportation 74.3 42.1 59.6 77.8 81
Supervision on System 68.4 38.5 68.5 56.3 40.5
Mass Media for distribution of information,
education and counselling (IEC) materials on 42.1 13.2 24.8 44.4 58.7
reproductive health.
Incentives and Disincentives 23.5 4.8 12 13.5 50
Evaluation 73.3 53 53.7 77.5 66.7
Record Keeping Systems 76 72.6 65 77 71.4
Programme Evaluation 72.5 53.2 51.6 76.2 69
Management’s Use of Evaluation Findings 71.3 33.3 44.4 79.4 59.5
Special populations
Unmarried Youth 42 23.6 26.2 28.6 12.7
The Poor 82.5 42.2 69 86.5 65.9
Rural Populations 79.6 35.6 71.4 84.1 84.9
Counseling and contraceptive services for
83.6 41.7 48.4 76.2 41.3
post-partum women
Counseling and contraceptive services for
60.4 32.5 40.5 66.7 45.2
post-abortion women
105
Accessibility 66.2 43.8 47.2 53.7 66.7
IUD 66.7 41.5 78.6 74.6 62.7
Contraceptive Pills 86.5 48.9 88.1 92.9 91.3
Injectables 71.9 27.8 83.3 46.8 80.2
Female Sterilisation 62.1 36.1 7.1 54.8 65.8
Male Sterilisation 49.4 25 0 1.6 59.5
Condoms 86 60.4 80.2 88.9 88.1
Implants 63.2 13.2 46.2 14.3 61.1
Emergency Contraception 57.4 35.4 23.1 42.1 42.1
Safe Abortion 36.6 37.5 2.4 16.7 55.6
Steterilisation Permanence 77.8 87.5 25.3 80.2 73
IUD Removal 72.6 76.4 77 80.2 62.7
Implant removal 64.8 36.3 55.6 52.1 57.9
Quality of Services 77.8 42.4 57.9 65.1 59.5
106
Table 11: Country Comparison using the National Composite Index on Family Planning375

2017 National Composite Index on Family Planning (NCIFP)
Total score 58.4 -- 61.6 59.5 63
Strategy 67.7 -- 67.6 65.9 78
Defined FP Objectives over a 5-10 year period,
63.6 -- 100 78.9 94.4
including quantitative targets
Reaching Vulnerable Polpulations with quality
81.8 -- 81.8 85.7 94.4
FP info and services
Resource Needs projected (material, human
and financial) to implement the Strategy and 81.8 -- 72.7 72.7 88.9
a plan to secure the resources
Participation of Diverse stakeholders 60 -- 27.3 65 66.7
High Level FP Support from director of the
national FP program and whether they report 72.8 -- 73.1 30.8 71.9
to a high level of government
Regulations Facilitate contraceptive supplies 46.3 -- 50.9 62.3 51.9
Data 67.1 -- 63.2 60.1 53.6
Private Sector Commodities 37.5 -- 75 45 55.6
Service Statistics Quality Control 90 -- 100 72.7 70.6
Data to Ensure FP servicess access to
66.7 -- 54.5 89.5 64.7
Vulnerable Populations
Adequateness of Clinical Record Keeping 77.8 -- 66.7 59.1 52
Data Used for Monitoring (program statistics,
69.1 -- 63 53.1 41.4
national surveys, and small studies)
Data Used by program managers for Program
68.1 -- 44.4 53.1 39.8
Improvement
375 FP 2020 (2017) National Composite Index on Family Planning (NCIFP)
107
Quality 53.7 -- 62.9 60 62.6
FP Standard Operating Procedures (SoPs)
70 -- 100 78.9 100
aligned with WHO
Tasksharing of FP services Guidelines 62.5 -- 58.3 60 61.1
Indicators of Quality of Care (QOC) collated
50 -- 91.7 88.9 94.4
by Public Sector FP services
QOC Indicators: Private Sector 16.7 -- 25 29.4 43.8
Structures to address QOC (Incl. participatory
monitoring or community/ facility quality 33.3 -- 27.3 80 72.2
improvement activities)
Information on informed choice and provider
14.3 -- 58.3 63.2 50
bias collected by government
Training for FP Personnel to effectively
57.8 -- 63.9 49.1 55.6
undertake tasks
Optimal FP Logistics and Supply System to
keep stocks of contraceptive supplies and
related equipment available at all service 57.8 -- 68.5 58.3 67.3
points, at all times and at all levels (central,
provincial, local)
Supervision System at all levels is adequate
(regular monitoring visits with corrective or 65.6 -- 72.2 42.1 40.7
supportive action)
Routine Counseling on Sterilisation Permanence 73 -- 42.2 59.3 67.9
Access to IUD removal 82.7 -- 83.3 63.9 56.1
108
Accountability 49.7 -- 62.9 57.8 65
Monitoring for Voluntarism: mechanisms at
national, subnational and facility level to
55.6 -- 75 77.8 94.4
monitor access to volintary, non-discriminatory
FP info and services
Monitoring for Denial of services: mechanisms
to report denial of services on non-medical
grounds (age, marital status, ability to pay) or 33.3 -- 72.7 40 47.1
coercion (including inappropriate use of
incentives to clients or providers)
Violations reviewed on a regular basis 33.3 -- 41.7 40 41.2
Mechanisms for Client Feedback 62.5 -- 50 55 63.2
Dialogue among FP Clients, Providers and
Officials about service availability, accessibility, 63.6 -- 75 76.2 78.9
acceptability and quality
Equity 55.2 -- 47.7 51.6 56.8
Policies to Prevent Discrimination toward
31 -- 25.2 45.6 49.2
special sub-groups
(Lack of) Provider Discrimination 68.9 -- 63.8 63.1 60.8
Community-based distribution (CBD) of
contraceptives for Hard to Reach Areas 58.9 -- 30.6 42.9 50.3
(particularly rural areas)
Access to long-acting and permanent methods
37.5 -- 41 32.4 47.1
(LAPMs)
Access to short-term methods of contraception
79.8 -- 77.8 73.8 76.8
(STMs)
109
110
PART II: REPRODUCTIVE HEALTH EDUCATION:
POLICY AND PLAN OF ACTION
111
112
NO TABLE OF CONTENTS PAGE
1. GLOSSARY 114
2. LISTS OF FIGURES AND BOXES 116
3. LISTS OF TABLES 117
4. EXECUTIVE SUMMARY 118
5. INTRODUCTION 122
Background 122
Objectives of Review 123
Approach of Review/ Update of PEKERTI PoA 2009-2012 123
6. CONCEPTUALISING SEXUALITY EDUCATION 124

The Evolution of Sexuality Education 124
Comprehensive Sexuality Education Curriculum Content 125
Comprehensive Sexuality Education Delivery Principles 125
Adapting the Comprehensive Sexuality Education Approach 127
Considerations For Adapting Comprehensive Sexuality Education in Muslim Countries 128
7. METHODOLOGY 130
Data Collection 130
Selection of Comparative Muslim Countries 130
Frameworks Guiding the Analyses of Selected Muslim Countries 131
8. FINDINGS 133
Policies Related to Sexual and Reproductive Health Education 133
• Sexual and Reproductive Health Education Programmes Across Selected Countries 135
• The Islamic Perspective of SRH Education and Gender Roles 146
• Knowledge of SRH Among Adolescents 147
• Barriers to Implementing Sexual and Reproductive Health Education 149
• Monitoring and Evaluation 150
9. DISCUSSION 154
Islamic Perspective of SRH Education 154
SRH Education Programmes 156
Linking SRH Education and SRH Programmes and Services 159
10. LIMITATION 160

11. CONCLUSION 161
12. RECOMMENDATION 163
13. APPENDIXES 165
113
GLOSSARY
ACCRH Advisory and Coordinating Committee for Reproductive Health

AFR Adolescent Fertility Rate
AIDS Acquired Immunodeficiency Syndrome
ALCS Association de Lutte Contre le Sida
AMPF The Association Marocaine de Planification Familiale
AOUM Abstinence Only Until Marriage
CEDAW The Convention on Elimination of All Forms of Discrimination Against Women
CPAP Country Programme Action Plan
CPR Contraceptive Prevalence Rate
CSE Comprehensive Sexuality Education
EFHS The Egyptian Family Health Society
FP Family Planning
FRHAM Federation of Reproductive Health Associations
GBV Gender Based Violence
GDI Gender Development Index
GII Gender Inequality Index
GNI Gross National Income
HDI Human Development Index
HIV Human Immunodeficiency Virus
ICPD International Conference on Population and Development
ICPD PoA International Conference on Population and Development Programme of Action
ICT Information and Communication Technology
IEC Information, Education and Communication
IMM Moroccan Modern Industries
IPPF International Planned Parenthood Federation
ITGSE International Technical Guidance on Sexuality Education
LPPKN Lembaga Penduduk dan Pembangunan Keluarga Negara
LMIC Low Income to Middle Income Countries
M&E Monitoring and Evaluation
MoE Ministry of Education
MoH Ministry of Health
MPFS Malaysian Population and Family Survey
MWFCD Ministry of Women, Family, and Community Development
MyCAP Malaysian Care for Adolescent Project
NAHP National Adolescent Health Policy
114
GLOSSARY
NCTB National Curriculum and Textbook Board

NGO Non-Governmental Organization
NPFDB National Population and Family Development Board
NSP National Social Policy
OPALS Organisation Pan Africaine de Lutte Contre le Sida
PEERS Pendidikan Kesihatan Reproduktif dan Sosial (Reproductive Health and Social Education)
PEKERTI Pendidikan Kesihatan Reproduktif dan Sosial (Reproductive Health and Social Education)
PEPFAR The President’s Emergency Plan for AIDS Relief
PKK Pendidikan Kesihatan Keluarga (Family Health Education)
PoA Plan of Action
RHSE Reproductive Health and Social Education
SBCC Social and Behavior Change Communication
SDG Sustainable Development Goals
SE Sexuality Education
SRHE Sexual and Reproductive Health Education
STI Sexually Transmitted Illness
SRH Sexual and Reproductive Health
SYPE The longitudinal Survey of Young People in Egypt
TWC Technical Working Committee
UN United Nations
UNESCO United Nation Educational, Scientific and Cultural Organization
UNICEF United Nations Children’s Fund
UNFPA United Nations Population Fund
YFS Youth Friendly Services
YHC Youth Healthcare Centers
YHS Youth-Friendly Health Services
WHO World Health Organization
115
LIST OF FIGURES
NO FIGURE PAGE
1. Figure 1: 131
Socio-ecological Approach Depicting Levels of Adolescents Influences.
LIST OF BOXES
NO BOX PAGE
1. Box 1: 141
PEER Education and Premarital Counselling Initiatives
2. Box 2: 145
National Conferences on Youth and Adolescents Health in Egypt
3. Box 3: 149
The longitudinal Survey of Young People in Egypt (SYPE)
4. Box 4: 152
Population Council’s Recommendations For Implementing SRH Education and
Services in Bangladesh
5. Box 5: 153
Evaluation of The Moroccan 2011 – 2020 National Reproductive Health Strategy
116
LIST OF TABLES
NO TABLE PAGE
1. Table 1: 132
UNFPA’s CSE Essential Principles and Key Intervention Areas
2. Table 2: 137
The Current Integration of SRH Topics In the PEERS Curriculum
3. Table 3: 140
Sexuality Topics Introduced in Bangladeshi Schools in 2012
4. Table 4: 166
Commitments to Key International Conventions/ Protocols Relevant to Reproductive
Rights and The Right to Sexuality Education
5. Table 5: 168
Contextual Information Across Selected Countries (2018 Data Mostly)
6. Table 6: 173
Summary of Malaysian Studies Assessing The Existing PEERS Curriculum
117
EXECUTIVE SUMMARY
Malaysia’s National Policy and Plan of Action (PoA) for Reproductive Health and Social Education
(RHSE) or Dasar dan Pelan Tindakan Pendidikan Kesihatan Reproduktif dan Sosial Kebangsaan
(PEKERTI) was incepted in 2009, and it was for the period 2009 – 2012. The PoA needs to be
reviewed and updated with information on new developments impacting on Sexual and
Reproductive Health (SRH) and Sexual and Reproductive Health Education (SRHE). The new PEKERTI
Policy and Plan of Action is for the period 2020-2024, and it aims to enhance the effectiveness of
comprehensive and age-appropriate RHSE in formal and informal settings in schools and out of
schools.
The evidence needed for the review/ update was generated by a desk review study, and this evidence
can be used to update the next PoA of the PEKERTI Policy.
The general objective of this study is to generate evidence enhance for the update of PEKERTI, in order
to improve the effectiveness of comprehensive and age-appropriate RHSE in formal and informal
settings in schools and out of schools and to cover all persons of all ages. The specific objectives
of the desk review are:
1. To consider the findings of the 2017 evaluation of the 2009-2012 PEKERTI’s PoA and other sources
of information to identify the strengths and weaknesses of PEKERTI;
2. To review SRHE across selected Muslim countries with a Sunni majority to provided information
for comparison that Malaysia can use; and
3. To propose recommendations to improve PEKERTI’s PoA.
The methodology involved:
1. Data collection methods;

2. Selection of comparative Muslim countries; and
3. Use of two (2) frameworks to guide the analysis of the findings.
A two-day brainstorming workshop was conducted by NPFDB where discussions were held with
selected experts and the researcher before the desk review was conducted. Four (4) countries to be
compared to Malaysia were selected - Bangladesh, Egypt, Morocco and Turkey.
118
The findings disclose similarities and also differences in the situation both in SRH and SRHE among
these five (5) countries, and in several aspects, Malaysia is doing better than the others. It can be
surmised and discussed from three (3) perspectives:
1. Islamic perspective of SRHE - The Sunni Muslim faith plays an important role in the acceptance of
SRHE and the extent to which governments are able or willing to promulgate laws and policies that
regulate SRH and SRHE. Governments tend to approach sensitive issues using less confronting
and more socially acceptable means, such as the use of terminology. Legal frameworks are also
influenced by religion – and a well-known example is abortion laws. It is undeniable that the Islamic
world is undergoing a transformation in its sexual discourse and needs to incorporate a more
progressive perspective of how sexuality, reproductive rights and women’s rights fit into society.
2. SRHE Programmes - Schools provide the ideal setting for sexuality education, as most children,
adolescents and young people are enrolled within the educational system. While there is some
form of school-based SRHE in these countries, they vary considerably at both policy and programme
levels. Several weaknesses are found - the curriculums are either not being implemented or being
poorly implemented due to teachers’ reluctance to teach SRHE which teachers are uncomfortable
teaching SRH-related information and parents are not engaged in the learning process. Very little
evaluation has been carried out, and few programs have been scaled up. Some has not been
extensively used or evaluated for impact. Out-of-school programs are critical to reach adolescents
outside the educational system. These services were limited across these five (5) countries with
poor uptake by adolescents and young people due to stigma or lack of awareness, particularly
in rural areas.
3. Linking SRHE and SRH Programmes and Services - In the countries reviewed, coverage and uptake
of youth-friendly services are poor, which requires awareness raising among adolescents’
teachers and guardians. Furthermore, health care providers should be capacitated to deliver
SRH information and confidential, non-judgmental and non-discriminatory services to both
married and unmarried demographics.
Specifically, it concluded that school-based SRHE programmes are cost-effective in reaching children,
adolescents and young people and at the same time, community-based out-reach interventions
are equally important in transforming harmful attitudes, beliefs and behaviours and ensuring access
to SRH information and services for most vulnerable groups, including out-of-school adolescents.
A significant gap remains in content and delivery, which needs to be addressed.
119
The recommendations from this review are:
1. Revive the Advisory and Coordinating Committee for Reproductive Health (ACCRH), overseen
by NPFDB which will look into the improvement of the quality of RHSE by improving
multisectoral collaboration and coordination.
2. Improve the SRHE curriculum and programmes by allocating adequate financial resources,
including personnel to build the capacity of SRH service providers and SRHE educators. Reframe
SRHE as a health issue (e.g. family health) appealing to contextual values and beliefs while
ensuring the adaptation of right-based and gender-focused principles to Malaysia’s multiracial
and multifaith society:
i. Adapt the school-based Comprehensive Sexuality Education (CSE) curriculum guidelines and
empower children, adolescents and young people in making informed decisions by
integrating four (4) key components:
a. rights, participation and agency;
b. SRH and behaviours;
c. gender equality and power; and
d. positive sexuality and respectful relations;
ii. Integrate CSE training in the teachers’ syllabus and improve training modules using a
participatory teaching approach with follow up and support;
iii. Engage parents in the learning process; engage the progressive community and faith-based
leaders in delivering a consistent community message to increase support;
iv. Improve reach and coverage of RHSE programs addressing vulnerable communities; and
v. Include the elderly within the PEKERTI’s PoA by strengthening SRH programmes and services
and SRHE for older persons.
3. Generate social support through community participation and mobilisation via mass media
campaign to advocate for greater community acceptance of RHSE and services accounting
for religious views and cultural perspectives, engaging champions from different sectors.
4. Use peer-based models to transform knowledge and attitudes among children, adolescents and
young people, and introduce digital innovations.
120
5. Establish a comprehensive monitoring and evaluation (M&E) mechanism prior to program
implementation.
6. Form a Task Force under the ACCRH to review the 2009-2012 PEKERTI document in terms of:
i. Overall structure;
ii. Comprehensiveness and length;
iii. Specific contents;
iv. Most appropriate timeframe; and
v. Ensure the publication of an official English version to facilitate international engagement.
121
INTRODUCTION
Background
Malaysia’s National Policy and PoA for Reproductive Health and Social Education 2009 (Dasar dan
Pelan Tindakan Pendidikan Kesihatan Reproduktif dan Sosial Kebangsaan or PEKERTI) is a policy, PoA
and programme. PEKERTI’s PoA includes all ages, although the programme is mainly targeted to
adolescents. The National Population and Family Development Board (NPFDB) or Lembaga Penduduk
dan Pembangunan Keluarga Negara (LPPKN), a statutory agency under the Ministry of Women, Family
and Community Development (MWFCD) overseers this PoA since it was introduced in 2009. Being
a National Policy, PEKERTI is endorsed and accepted by all Ministries and agencies, and should be
implemented by relevant agencies. The current PEKERTI Policy and PoA were for the period
2009-2012. The salient features are in Appendix 1.
The new PEKERTI’s PoA is for the period 2020-2024, and it aims to enhance the effectiveness of
comprehensive and age-appropriate RHSE in formal and informal settings in schools and out of schools.
While NPFDB oversees and coordinates the overall PEKERTI, it is implemented by several agencies,
including the Ministry of Education (MoE) which provides SRHE in schools and the Ministry of Health
(MoH) which is the main provider of SRH services including counselling in clinical and community
settings via health clinics and Adolescent Health Services. NGOs, notably the Federation of Reproductive
Health Associations of Malaysia (FHRAM), use PEKERTI to provide RHSE to vulnerable groups.
In 2017 evaluation of PEKERTI by NPFDB and MWFCD376 recommended the urgent review of the
2009-2012 PEKERTI’s PoA. PEKERTI needs to be renewed with information on new developments
impacting on SRH including RHSE (new communication technologies, changes in population dynamics
and demographic trends, trends in SRH status and in the knowledge of Malaysians on SRH and also
the changes in capacity). This review and update of PEKERTI (2009-2012) are critical for Malaysia to
fulfil its international commitments, particularly to the International Conference on Population and
Development (ICPD) and the Sustainable Development Goals (SDG).
376 NPFDB & MWFCD (2017) Draft Evaluation Report of the Implementation of Reproductive and Social Health Policy and Plan of Action
122
Objectives of Review
The general objective is to generate evidence enhance for the update of PEKERTI in order to improve
the effectiveness of comprehensive and age-appropriate SRHE in formal and informal settings in
schools and out of schools and to cover all persons of all ages.
The specific objectives are:
1. To consider the findings of the 2017 evaluation of the 2009-2012 PEKERTI’s PoA and other sources
of information to identify the strengths and weaknesses of the PEKERTI’s PoA;
2. To review SRHE across selected Muslim countries with a Sunni majority to provided information
for comparison that Malaysia can use; and
3. To propose recommendations to improve the new PEKERTI Policy’s PoA.
Approach of Review/ Update of PEKERTI PoA 2009-2012
A Technical Working Committee (TWC), chaired by NPFDB’s Deputy Director General (Policy) was
established to oversee this review. The TWC includes membership from key government and
non-government stakeholders involved in various aspects of promoting SRH.
A brainstorming workshop was conducted by NPFDB on 10-12 August 2020 where discussions were
held with between NPFDB, United Nation’s Population Funds (UNFPA), the researcher tasked with
the study to generate the evidence, other stakeholders and experts.
While the scope and focus of the review are on SRHE, the desk review also includes SRH services.
It is to be acknowledged that one (1) of the core concepts of SRHE is that it must be linked to the
broader SRH programmes and services. The desk review was based on a mapping of relevant
UNFPA guidelines and similar international frameworks as well as related sexuality education
policies and PoA of selected Muslim countries with Sunni Muslim majority demographics.
123
CONCEPTUALISING SEXUALITY EDUCATION
The Evolution of Sexuality Education
The 1994 International Conference on Population and Development Programme of Action (ICPD PoA),
adopted by 179 member-states introduced a comprehensive definition of reproductive health implying
the right of men and women to be informed and have access to safe, effective, affordable and
acceptable family planning (FP) methods of their choice. These universal rights imply the provision of
sexuality education and services to all demographic groups and all ages.
The extent of comprehensiveness of SRHE can differ across different countries and communities.
In general, it can be perceived as three (3) types:
1. At one (1) extreme of the spectrum, the Abstinence Only Until Marriage (AOUM) approaches
teach adolescents that the only morally correct option is abstinence, discourages pre-marital
sexual relationships and censor information about contraception and condoms for preventing
STIs and unintended pregnancies. With delaying of age at first marriage, many adolescents
engage in premarital sex. Abstinence intentions often fail and are not sustained, and AOUM
programmes provide incomplete information, including medically inaccurate and stigmatising
information377. AOUM interventions have also been proven unsuccessful in delaying initiation
of sexual activity or modifying related sexual behaviours (e.g. preventing unprotected sex) and in
reducing the incidence of STIs or unintended pregnancies378,379.
2. In the middle is the Abstinence-Plus Education approach, which includes information about
contraception and condoms in the context of strong abstinence messages. These programmes
acknowledge that many teenagers will eventually become sexually active, so the curriculum
includes information on contraceptive protection from STIs and unwanted pregnancy as well
as abortion. This approach has protective effects for behavioural or biological outcomes
including the delay of sexual initiation, reduction of sexual activity and reduction of incidence
and frequency of unprotected sex but limited evidence on reducing pregnancy incidence
and no conclusive evidence of impact on STI incidence380.
377 Santelli J, Grilo SA, Lindberg LD, et al (2017) Abstinence -only-until-marriage policies and progams: An updated position paper of the Society for Adolescent
378 Health and Medicine. J Adolesc Health 61:400-403.
379 Silva M (2002) The Effectiveness of school education programs in the promotion of abstinent behaviour: a meta-analysis. Health Educ Res 17:471-481.
380 Trenholm C, Devaney B, Fortson K, et al (2007) Impacts of Four Title V, Section 510 Abstinence Education Programs. Final Report. Methamatica Policy Research, Inc
Underhill K, Operario D, Montgomery P (2007) Systemic Review of Abstinence-Plus HIV Prevention Programs in High-Income Countries. PLOS Medicine 4:e275.
124
3. At the other end of the spectrum is Comprehensive Sexuality Education which aims at enhancing
capacity for educated, safe and respectful sexual choices. While CSE primarily teaches abstinence
as the best method for avoiding STIs and unintended pregnancy, it also provides age-appropriate
information (starting at age 5) on contraception and condoms to reduce risks and incorporates
interpersonal and communication skills and girls’ empowerment components to support children,
adolescents and young people in their experiences381. CSE is an effective intervention for
generating HIV-related knowledge and decreasing sexual risk behaviours, and it is increasingly
recognised as the most effective approach.
Comprehensive Sexuality Education Curriculum Content
This desk review examined several guidelines including the 2010 International Planned Parenthood
Federation’s Framework for CSE, World Health Organization (WHO)’s Standards for sexuality education
in Europe, the 2018 United Nation Educational, Scientific and Cultural Organization (UNESCO)’s
International Technical Guidance on Sexuality Education (ITGSE) and the 2014 UNFPA’s Operational
Guidance for Comprehensive Sexuality Education. The theoretical and normative elements of CSE
are continually expanding and evolving in response to emerging evidence and technical and social
innovations. The core components are synthesised into four (4) broad and interlinked themes:
1. rights, participation and agency;

2. SRH and behaviours;
3. gender equality and power; and
4. positive sexualities and respectful relations.
Comprehensive Sexuality Education Delivery Principles
Schools are primary settings for the implementation of CSE, which might be delivered either as a
stand-alone subject or integrated within other subjects or be mandatory or optional. Health centres and
community-based settings also provide opportunities for CSE, particularly for reaching vulnerable out-
of-school adolescents and the broader community. CSE should be developmentally appropriate and
preferably incremental, starting at an early age382. A quality CSE curriculum is broader than SRH
and should cover contextual and relevant SRH issues such as respect, responsibility and gender
relations. It involves the active participation of students in discussing such issues and includes
referrals to relevant available SRH services.
381 Vanversenbeeck I (2020) Comprehensive Sexuality Education. In: OxfordResearch Encyclopedia of Global Public Health. Oxford University Press.
382 UNESCO (2018) International Technical Guidance on Sexuality Education
125
While no systematically and validated training programmes exist for teachers and allied health
professionals on sexuality education, these should cover cultural and contextual knowledge,
attitudes, values and behaviours in adolescent sexuality. Teachers should be familiar with arguments
for and against abstinence and CSE. More research is needed examining the factors influencing
teaching and learning processes and outcomes in sexuality education (e.g. how programmes, people,
processes, policies and places influence the outcomes of school-based education)383.
The ITGSE outlines eight (8) concepts which are equally important and mutually reinforcing and
intended to be taught collectively considering age appropriateness and increasing complexities.
The learning objectives can be interpreted by national curriculum developers and made measurable
based on the local context and/ or existing standard and frameworks based on the contextual needs
(sociocultural norms and epidemiological context). While certain content might not be acceptable
in some countries, each nation should ensure a human rights and non-discriminatory approach
and experts recommend starting teaching age-appropriate sexuality education as early and
comprehensively as possible (preferably from age 5).
The WHO guidelines provide an overview of the components of competencies of educators for
delivering holistic sexuality education384 which includes:
1. a set of attitudes (commitment to sexuality education; respect for integrity and understanding of
boundaries and open-mindedness and respect for others);
2. skills (ability to create and maintain a safe, inclusive and enabling learning environment; to use
interactive teaching and learning approaches; to communicate effectively; and to reflect on
beliefsand values); and
3. knowledge (about relevant topics in sexuality education; health promotion and psychology;
of methods on how to deliver sexuality education; and about different sexuality education
approaches and their impact).
383 Leung H, Shek DTL, Leung E, Shek EYW (2019) Development of Contextually-relevant Sexuality Education: Lessons from a Comprehensive Review of Adolescent
Sexuality Education Across Cultures. International Journal of Environmental Research and Public Health 16:621.
384 WHO Regional Office for Europe and BZgA. (2017). Training matters: A framework for core competencies of sexuality educators. Cologne: Federal Centre for Health
Education (BZgA).
126
Adapting the Comprehensive Sexuality Education Approach
CSE which requires an awareness of cultural (ideological, religious, political) contexts and of the
ways they affect people’s sexual choices, behaviours, and relationships. Different sexual approaches
are implemented in different societies. International reviews385,386 note significant progress in CSE
implementation in most developed countries, although a gap remains between legal frameworks
and the actual implementation, with few policies being fully operationalised.
In most Low Income to Middle Income Countries (LIMIC)s, CSE is not yet being institutionalised387, and
there are many barriers to effective implementation388. CSE approaches are primarily promoted in
the Global North, while CSE and abstinence-only and abstinence-plus interventions approaches are
applied in the Global South389 and the US and its foreign aid programmes such as The President’s
Emergency Plan for AIDS Relief (PEPFAR)390. Sexual education content is also prioritised differently for
adolescents: sex positive approaches, pleasure and personal wellbeing are emphasised in some
European countries, while CSE initiatives for adolescents in the Global South are mainly driven by
SRH related issues and attaining broader development goals391.
A 2019 comparative review of adolescent sexuality education across cultures (US, UK, China, Hong Kong
and Taiwan)392 identified many gaps and inadequacies in sexuality education. There are limited
evidence-based sexuality education programmes including evaluations, particularly in the Asian
context and a lack of evidence-based policies; it is necessary to foster multi-disciplinary
collaboration where students and parents as the main stakeholders should be invited to co-design
school-based sexuality education policy and programmes (along with teachers, youth workers,
counsellors, health care workers and religious leaders).
Education (BZgA).
386 UNESCO (2015) Emerging evidence, lessons and practice in comprehensive sexuality education: a global review
387 Haberland, N. A. (2015). The case for addressing gender and power in sexuality and HIV education: A comprehensive review of evaluation studies. International
Perspectives on Sexual and Reproductive Health, 41(1).
389 Miedema E, Le Mat MLJ, Hague F (2020) But is it comprehensive? Unpacking the ‘comprehensive’ in comprehensive sexuality education. Health Education Journal
0017896920915960.
391 Miedema E, Le Mat MLJ, Hague F (2020) But is it comprehensive? Unpacking the ‘comprehensive’ in comprehensive sexuality education. Health Education Journal
0017896920915960.
127
Sexuality education programmes should be culturally relevant to address the local needs by identifying
behavioural goals, their determinants and strategies via intervention mapping with a protocol for
developing effective behaviour change interventions393. The ITGSE were developed in global
consultation and was limited in terms of sexual rights in order to gain consensus. The CSE guidelines
should be adapted to what can reasonably be expected in particular socio-cultural contexts and
religious sensitivities394. The World Starts With Me programme has adapted CSE to a wide range of
socio-cultural contexts.
Considerations for Adapting Comprehensive Sexuality Education in Muslim Countries
This section is particularly relevant to Muslim countries who adopted the agreements from the 1994
ICPD and the 2012 United Nations (UN) Commission on Population and Development focused
on young people, with reservations in implementing the recommendations within the Islamic Law
framework. The ICPD PoA and other agreements state that individual countries have the sovereign
right to contextualise policies and programmes to conform to customary laws, values and cultures.
Still, interventions should uphold individual rights and respond to the complex needs of adolescents
in the process of physical, cognitive, emotional, social and moral development395.
The Holy Quran addresses the issues of sexuality and sexual needs as being a fundamental part of
our human identity. While western culture views sexuality and sexual needs as individual rights, the
Islamic teachings view them as fundamentally bound to responsibility and social accountability396.
Puberty is a period of increased guidance in Islam. General Islamic sex education for children focuses
on ethics in controlling desires (from the way an individual sees other to one’s sexual desires),
respecting aurat (or parts of the body that should be covered), focusing on worshipping to stay
away from sexual desires which might come from media or peers, considering commandments
related to puberty and maintaining communication with parents. Parents and educators should
provide age-appropriate guidance to children, so they understand sexuality based on Islamic
values397.
393 Vanwesenbeeck I (2020) Comprehensive Sexuality Education. In: Oxford Research Encyclopedia of Global Public Health. Oxford University Press
394 Miedema E, Le Mat MLJ, Hague F (2020) But is it comprehensive? Unpacking the ‘comprehensive’ in comprehensive sexuality education. Health Education
Journal 0017896920915960. Source: Vanwesenbeeck I, Westeneng J, Boer T de, et al (2016) Lessons Learned from a Decade Implementing Comprehensive
Sexuality Education in Resource Poor Settings: The World Starts with Me. Sex Education.
396 Ihwani SS, Muhtar A, Musa N, et al (2017) An overview of sex education: comparison between Islam and Western perspectives. al-Qanatir: International Journal
of Islamic Studies 8:43–51
397 Desiningrum DR, H DI (2018) Sexual Education For Children With Islamic Psychological Approach. Proceeding Annual International Conference on Islam and
Civilization 1:
128
Adapting any CSE curriculum models in Muslim countries should consider the negative connotations
that extramarital sex has in Islam. However, religious doctrine and scientific evidence should be
non-conflicting sources for formulating a culturally sensitive and innovative programme398.
In the BACKGROUND section of this review, it was noted that the term social instead of sexual/
sexuality used for PEKERTI reflects the local cultural and religious reality. This is also the rationale
for this desk review to study the situation in other Muslim countries, where the population is mainly
adherents of the Sunni faith (although belonging to the different mazhabs or schools of Islamic
thought).
398 Horanieh N, Macdowall W, Wellings K (2020) Abstinence versus harm reduction approaches to sexual health education: views of key stakeholders in Saudi Arabia.
Sex Education 20:425–440.
129
METHODOLOGY
The methodology involved:
1. data collection methods;
2. selection of comparative Muslim countries; and
3. use of two (2) frameworks to guide the analysis of the findings.
Data Collection
A combination of data collection methods was used to meet the study objectives, including a desk
review of relevant documents and several stakeholder consultations;
Document review: a set of relevant documents were reviewed including national and international
policy documents related to SRH, national data and population surveys and census reports; evidence
from reports (government, development partners and multilateral agencies); independent studies
and journal articles including systematic reviews. The desk review also included research publications
and grey literature (i.e. annual reports, strategic plans, donor reports) that aligns with the outcomes
and criteria being pursued to provide evidence of best practice.
Consultative meetings: The research consultants presented the research proposal with an initial
literature review, methodology and work plan (detailing the scope of work, approach, timelines for
consultations and deliverables) to NPFDB and UNFPA partners at a pre-inception meeting and inception
meeting to LP NPFDB’s TWC. A Workshop with key stakeholders from related government and non-
government agencies was carried out to inform the draft 2020-2024 PEKERTI’s PoA.
Selection of Comparative Muslim Countries
The selection of comparative Muslim countries was based on an objective criterion and input from
the TWC. A list of countries that align with Malaysia’s Sunni faith were initially proposed. An objective
selection criterion was then applied to proposed countries comparing contraceptive prevalence
indicators, commitments to key international conventions relevant to SRH and rights and the existence
of FP strategies and SRHE PoA (including the level of integration of FP policies into health care
programmes, Islamic leaders support and committed public budgets for FP programmes). This selection
process identified Bangladesh and Egypt as best candidates for further country comparisons, with best
contraceptive prevalence progress indicators.
The TWC suggested the incorporation of Morocco and Turkey as they are more similar to Malaysia’s level of
human and economic development. They finally agreed comparative countries are Turkey, Morocco,
Egypt and Bangladesh.
130
Frameworks Guiding the Analyses of Selected Muslim Countries
Two (2) frameworks were used to conduct the desk review and comparative analysis.
Socio-ecological framework - A comprehensive analysis of barriers and facilitators of CSE

implementation within an adolescent's environment including the relevant stakeholders that
influence their decision-making, enables the design of strategies targeted to each level of influence
and actively engages influencers to successfully reach adolescents, transform harmful social and
gender norms. Figure 1 shows that comprehensive, multilevel strategies are required to facilitate an
enabling environment in which adolescents’ rights are promoted, reinforced and practised399, starting
with the individual, the family and peers, the community and the social and structural environment.
Figure 1: Socio-ecological Approach Depicting Levels of Adolescents’ Influences 400
SOCIAL & STRUCTURAL

Leadership Religious & cultural values
Resources & services Gender norms
Policies & regulations Media & technology
Guidance & protocols Income equlity
COMMUNITY
Leadership
Access to information
Social capital
Collective efficacy
FAMILY & PEER NETWORKS

Peer influence
Spousal communications
Partner & family influence
Social support
INDIVIDUAL
Knowledge
Skills
Benefits & values
Self-efficacy
Perceived norms
Perceived risk
Emotion
399 Chandra-Mouli V, Plesons M, Hadi S, et al (2018) Building Support for Adolescent Sexuality and Reproductive Health Education and Responding to Resistance in
Conservative Contexts: Cases From Pakistan. Glob Health Sci Pract 6:128–136.
400 USAID (2017) Guide for promoting sexual and reproductive health products and services for men.
131
UNPFA framework - UNFPA’s 2014 CSE operational guidance401 outlines nine core principles in CSE
programmes and curricula as noted in Table 1.
Table 1: UNFPA’s CSE Essential Principles and Key Intervention Areas
9 essential principles of CSE programmes

based on evidence.
Key intervention areas
1. A basis in the core universal values of human Key intervention area 1: Strengthen policies and
rights. UNFPA considers human rights to be a advocate for large-scale, sustainable sexuality
core component of, not an add-on to CSE. education that is comprehensive and reaches young
people both in and out of school. This intervention
2. An integrated focus on gender. Programmes includes five (5) priority elements (refer to UNFPA’s
should focus on gender in a number of ways. 2014 CSE guidelines for respective actions against
Gender may be a stand-alone topic within the priority elements):
CSE curriculum. Gender can be used to highlight
• Assess the policy environment;
the ways it influences puberty, sexuality, SRH
• Ensure that managers and educators understand CSE;
and HIV risk.
• Provide leadership in advocating for and establishing
large-scale CSE programmes to be implemented in
3. Thorough and scientifically accurate information.
both formal and informal settings;
4. A safe and healthy learning environment. • Encourage CSE programmes to establish goals and
objectives that align with ICPD PoA; and
5. Linking to SRH services and other initiatives that • Build the evidence base to further inform policy
address gender, equality, empowerment, and debates and encourage investment.
access to education, social and economic assets
Key intervention area 2: Build technical capacity to
for young people. strengthen programme quality, with a focus on CSE
curricula, pedagogy and teacher training.
6. Participatory teaching methods for personalization
of information and strengthen skills in
Key intervention area 3: Enhance protective social
communication, decision-making and critical
factors beyond the CSE curriculum and pedagogy to
thinking. encompass young people’s learning and social
environment.
7. Strengthening youth advocacy and civic
engagement.
Key intervention area 4: Ensure that CSE programmes
include sound M&E components with due
8. Cultural relevance in tackling human rights
consideration to inequality, gender norms, power
violations and gender inequality.
in intimate relationships, and intimate partner
9. Reaching across formal and informal sectors and violence. This also involves ensuring a gender- and
human rights-based approach to M&E of CSE, which
across age groupings.
is the core of key intervention area 4.
401 Extracted from UNFPA (2014) Operational Guidance for Comprehensive Sexuality Education: A Focus on Human Rights and Gender
132
FINDINGS
This is the main theme and scope for this review with the primary objective of generating evidence to
provide information for the 2020-2024 PEKERTI’s PoA. The findings presented include:
1. the relevant policies and plans regarding SRHE;

2. SRHE programmes and interventions (covering school-based, out-of-school and community-based
interventions);
3. an overview of the Islamic perspective on SRHE;
4. the knowledge of adolescents on SRH (which is a reason for and an outcome of SRHE);
5. the barriers to SRHE; and
6. the M&E of SRHE programmes across the countries under review.
Policies Related to Sexual and Reproductive Health Education
A 2019 comparative review of adolescent SRHE across cultures identified many gaps and
inadequacies where different policies are implemented in different societies. The evidence-based
programs for sexuality education including evaluations are limited, particularly in the Asian context,
and there is a lack of evidence-based policies402.
Malaysia
In Malaysia, the MoH developed the National Adolescent Health Policy (NAHP) in 2001 and the
2006-2020 National Adolescent Health Plan of Action (NAHP PoA) in 2007 to empower adolescents
(aged 10-19 years) with the appropriate knowledge and assertive skills to enable them to practice
healthy behaviours and lifestyles403. SRH is one (1) of the five (5) priority areas outlined in the
NAHP PoA, which operationalises the seven (7) strategies of NAHP via a set of activities developed
by government and NGOs working with adolescent programmes404. In Malaysia, RHSE is mainly
provided by the MoE and NPFDB. MoH provides SRHE to clients who walk into their service centres,
whereas NPFDB, MoE and the NGOs provide RHSE to target groups.
403 Sexuality Education Across Cultures. International Journal of Environmental Research and Public Health 16:621.
Ministry of Health Malaysia (2015) National Adolescent Health Plan of Action
133
Turkey
The Turkish 2013-17 National Strategic Health Plan included raising awareness of reproductive
health and encourage healthy behaviours as an objective to be achieved by changing individuals’
behaviours through programmes and activities aimed at promoting reproductive health, improving
reproductive health services, improve reproductive health services for abortions and improve the
effectiveness of pre-marital counselling services via intersectoral cooperation405. Turkey does
not have a national multisectoral young people policy. Preoccupation with women’s chastity led
to Statute for Awards and Discipline in High School Education in 1995, which stated that proof of
unchastity was a valid reason for expulsion. This resulted in many suicides among girls who were
forced to undergo virginity tests. In 2002, after advocacy from Turkish women’s movement and
international Human Rights organisations, the MoE abolished the proof of unchastity clause406.
Turkey ratified The Convention on Elimination of All Forms of Discrimination Against Women
(CEDAW) in 1985, and the CEDAW Committee made the following recommendations407 including
ensuring the integration into the school curricula of mandatory, age-appropriate SRHE, particularly
the prevention of STIs, early pregnancies and violence as well as equal and full access to SRH
information and services including refugees and asylum seekers women and girls to safeguard the
legal right to abortion and contraception and renew the national strategic action plan for HIV/ AIDS.
Egypt
According to a 2013 report by the Egyptian Initiative for Personal Rights, no single institution is
dedicated to offering SRHE services in Egypt. Despite some government support of existing civil
society initiatives, particularly by the National Council on Motherhood and Childhood, the necessary
institutional and political framework for SRHE is lacking408. However, an expected outcome of the
2015-30 NPS is to have young people and reproductive age population educated on FP methods
and promote the value of a smaller family value, SRH and GBV via sports festivals (demand-side),
targeting governorates with highest fertility and poverty via NGOs door-to-door visits and training
religious and community leaders across religions (Muslim, Christian) on FP409.
No information on SRHE policies was found for Morocco or Bangladesh, although we can assume their
existence as SRHE is being conducted albeit limited as is noted below. This section provides
information on SRHE across settings including schools, out of school and other community initiatives.
405 WHO (2015) Strategic planning for health: a case study from Turkey
406 Nagi M (2017) Islam, Sexualities and Education. In: Daun H, Arjmand R (eds) Handbook of Islamic Education. Springer Internatiol Publishing, Cham, pp 1–26
134
Sexual and Reproductive Health Education Programmes Across Selected Countries
1. School-based SRH Programs
The introduction of SRHE into the school curriculum is considered the most effective and cost-efficient
initiative for reducing STIs and HIV infection and unintended pregnancies among adolescents410.
School-based programmes increase adolescents’ awareness, knowledge and understanding of SRH
issues via sessions delivered on school premises and built into students’ schedules. They reach large
numbers of adolescents at once and foster strong sustained participation as part of the regular
school day and involve the active participation from teachers and school management, legitimising
SRHE for adolescents, their parents and other gatekeepers411.
A whole-school approach has been effective in delivering quality SRHE and building the support
of the gatekeepers (teachers and parents) for the SRHE curricula. This approach involves the
participatory engagement of parents, teachers, community and leaders and progressive religious
figures; engaging men and boys in SRH issues such as equality, empowerment and human rights;
building partnerships with community, service-related resources and NGOs and making SRHE
mandatory across all. Adaptation of the whole-school approach combined with critical pedagogy
methods (a curriculum based on students’ interests, cultural needs and community empowerment;
a participatory teaching approach to promote dialogue; and space for critique and reflection
among students and teacher) should include a gender and power relations analysis framing the
discussions412.
Malaysia
In Malaysia, RHSE was introduced by the MoE in secondary schools’ curriculum in 1989 and was further
extended to primary schools in 1994 via the Family Health Education curriculum413.
In 2011, the RHSE curriculum was updated and renamed as Reproductive Health and Social
Education (Pendidikan Kesihatan Reproduktif dan Sosial, known as PEERS) and implemented in primary
and secondary schools from Year 1 to Form 5 (ages 7-18 years)414.
412 Gunasekara V (2017) Coming of age in the classroom: religious and cultural barriers to Comprehensive Sexuality Education. ARROW
413 Ministry of Education, Pelaksanaan Pendidikan Kesihatan Reproduktif Dan Sosial (PEERS) Melalui Kurikulum Pendidikan Kesihatan
135
The PEERS curriculum incorporated a range of topics from personal hygiene to life skills, self-
respect and negotiation skills emphasizing moral values taught by trained teachers for 30 minutes
per week in primary schools and 40 minutes per fortnight in secondary schools415. The PEERS
curriculum is integrated into subjects such as physical education, health, Islamic studies, biology,
science, and moral and physical education416 considering the context, religion and culture of
pupils417.
MoE has collaborated with governmental and non-governmental agencies in implementing PEERS
and with NPFDB in implementing PEKERTI. PEKERTI@School is a holistic and comprehensive
programme that encompasses the biological, socio-cultural, psychological and spiritual aspects
of SRHE. The “I’m in control” module is run by NPFDB for PT3 students (Secondary/ Form 3), and
Reproductive Health for Adolescent module is run by Federation of Reproductive Health Associations,
Malaysia (FRHAM) for Primary Six pupils during 2011-15. MoE has allocated 16 hours per year to
Health Education, and its scope addresses social problems such as sexual abuse and paedophilia.
The Family Health Education (PKK) module integrates language, science, additional science, biology,
health, life skills, Islamic and moral subjects. In Health class, PKK is given a special focus for pupils
from year one to form five (primary and secondary students). PKK is divided into five (5) modules,
namely:
i. Physical;
ii. Social;
iii. Gender;
iv STDs/ STIs; and
v. HIV/ AIDS.
MoE identified teachers who were qualified and capable to teach PEERS and proposed programmes
such as Parental Support (Sarana Ibu Bapa) or Community-Owned Schools (Sekolah Milik Masyarakat)
for parents and the society to educate students on sex education418. However, the current curriculum
excludes information on safer sex and contraception (see Table 2)419,420 and the content is non-
examinable421. Feedback from teachers noted the shortcomings in training, support, school
leadership and commitment422.
417 Information provided by the MoE representative within the TWC
418 Information provided by the MoE representative within the TWC
420 Mokhtar MM, Rosenthal DA, Hocking JS, Satar NA (2013) Bridging the Gap: Malaysian Youths and the Pedagogy of School-based Sexual Health Education.
Procedia - Social and Behavioral Sciences 85:236–245.
136
Table 2: The Current Integration of SRH Topics in the PEERS Curriculum423
Level Age category PEERS content Subject

Primary levels Children aged Physical differences between boys and girls Physical and
1,2 and 3 7-9 Personal hygiene, responding to social situations that Health
may lead to unsafe sexual contact, the importance of Education
preserving one's self-respect and emotional management
Primary levels Early Conflict management, puberty and physical changes, Family Health
4,5 and 6 adolescents the reproductive system, skills needed to preserve
aged 10-12 one's self-respect, the risks of premarital sex, the
spread of STIs, how to refuse cigarettes, alcohol and
narcotics.
Secondary levels Middle Social psychology, life skills needed to handle high- Biology,
7,8 and 9 adolescents risk situations, stress management, the transmission of Science,
aged 13-15 STIs, sexual growth traits, identity and sexual orientation, Islamic
relationships and the adverse effects of alcohol, education,
cigarettes and narcotics. Moral
Secondary levels Middle Social psychology, emotional and mental stability, Physical and
10,11 and 12 adolescents youth pregnancy, family issues, the spread of STIs and Health
aged 16-18 preventive measures againts cigarettes and narcotics. Education
Turkey
In Turkey, implementation school-based SRHE programmes is very limited (some agree that is
practically non-existent) in the national secondary and tertiary curriculums due to religious, dogmatic
and conservative politics (sexuality is seen as a taboo) 424,425. An evaluation of the integration
of SRHE into the 2002-03 school curricula (1-8 grades; ages 7-14 years) by the Development
of Health Awareness in Adolescent Project Science Committee concluded there are important
aspects missing, particularly in physical development and sexuality and sexual development,
including pregnancy and birth, unintended pregnancy, sexual identity, changes in adolescence,
sexual violence and abuse, birth control and sexual discrimination, which were not covered
at all.426 SRHE in Turkey is an unmet need for young people, particularly vulnerable girls.
423 Table extracted from Hazariah AHS, Fallon D, Callery P (2020) An Overview of Adolescents Sexual and Reproductive Health Services Provision in Malaysia.
Comprehensive Child and Adolescent Nursing 0:1–17.
424 Sayin U (2015) Problems in Sexual Education and Sex Therapy in Turkey. International Anatolian Twin Congress on Neuroscience and Sexual Health, 1-3 May,
2015 at: Kozyatagi-Hilton, Kadiköy-Istanbul-Turkeyaffiliation: Istanbul University
425 Bikmaz FH, Guler DS (2007) An Evaluation of Health and Sexuality Education in Turkish Elementary School Curricula. Sex Education: Sexuality, Society and
Learning 7:277–292
137
Information on reproductive health is only provided to secondary school students in biology lessons
as part of the national curriculum, and only very restricted information is offered on human
reproduction427. In university, sex education is rarely referenced, and very few universities
offer an elective sex education course428. Medical courses do not cover SRH issues from a
rights-based perspective, and health professionals have low knowledge about HIV infection
and high prejudices against people living with HIV, which discourages health-seeking behaviours
for those affected429. Several attempts have been made to pilot CSE school programs.
Egypt
In Egypt, apart from some government support of existing civil society initiatives, particularly by the
National Council on Motherhood and Childhood, the necessary institutional and political framework
for SRHE is lacking. While a few short lessons on reproductive health were introduced about
reproductive physiology and FP by the MoE in the science curricula for students in the preparatory
and secondary stages post 1994 ICPD, the content was particularly inadequate430. Reproductive
health was part of the health education curriculum, introducing in FP and the impact of population
growth in Egypt in the syllabus of religious studies in grades 9 and 12. The science syllabus for the
second year of preparatory school (grade 8) contained a description of the structure and functions
of the male and female genital systems along with a brief mention of reproduction. The only genital
diseases discussed were puerperal sepsis (genital infection after delivery) and syphilis.
However, following the 2011 revolution and the subsequent political instability, the newly
appointed minister ordered the removal of these topics along with FP methods from the
12th-grade curriculum431. By 2017, limited aspects of SRH topics were covered by Egyptian public
schools and little is known about how well this subject is delivered or how students react to it.
In most Egyptian classrooms, if SRH topics are covered, it is under biology and not presented in detail.
SRH sections might be skipped or covered inadequately because teachers are unprepared or
embarrassed432.
427 Yilmaz V & Willis P (2020) Challenges to a Rights-Based Approach in Sexual Health Policy: A Comparative Study of Turkey and England. Societies 2020, 10, 33.
428 Alper Çuhadaroğlu (2017) The effects of sex education on psychological counselling students in Turkey, Sex Education, 17:2, 209-219,
429 Yilmaz V & Willis P (2020) Challenges to a Rights-Based Approach in Sexual Health Policy: A Comparative Study of Turkey and England. Societies 2020, 10, 33.
431 Wahba M, & Roudi-Fahimi F. (2012) Policy Brief: The Need for Reproductive Health Education in Schools in Egypt. Population Reference Bureau
138
A 2012 study conducted in three (3) governorates of Egypt revealed that students consider the
SRH school-based curriculum is insufficient where teachers and students are shy and embarrassed
during these lessons433. Teachers do not always deliver the curriculum upon which they often ask
pupils to read it at home or discuss it with their parents, and the lesson content is not examined.
The topic is revisited in 12th-grade biology (the last year of secondary school)434. However,
successful school pilots have been implemented, although very few have been scaled-up.
Morocco
SRHE remains a controversial issue in Morocco and CSE is absent from schools. Public schools must
deliver a class called Education in Health Reproduction to the last year of middle school and the first
two (2) years of high school. The curriculum includes biological information on human reproduction
but omits other aspects of sexuality and begins at the end of the school year and attendance is not
enforced435. However, the 2011-20 Strategy noted that an SRHE programme is delivered in schools
and universities, including FP methods and contraceptives and SRH modules were introduced in the 5th
and 6th year of Medicine courses covering STIs, prenuptial consultation, uterine, cervical and breast
cancer among other SRH topics, although no specific information was found about the SRH
curriculums. In 2014, the Moroccan Ministry of National Education and the Moroccan Modern
Industries (IMM) agreed to implement a new programme to sensitise and educate young people in
schools in hygiene practices, life skills, STIs prevention, early marriage and FP, but no further
information was found on this436.
Bangladesh
In 2012, the Bangladeshi government’s National Curriculum and Textbook Board (NCTB) within the
MoE introduced content on adolescence and reproductive health for the curricula standards for
classes 6 to 10 (Table 3), although it was not covered in great detail. While no research is available
on the implementation or effectiveness of the national SRH curriculum, reports indicate it is not being
implemented due to teachers’ reluctance to teach SRH in classrooms.
Students are asked to read these chapters on their own, as teachers are not comfortable discussing
topics that are perceived as sensitive. More sensitisation, training, and support for teachers is required
for effective implementation along with strong research designs and rigorous M&E.
433 Geel FEZ (2012) Quality Sexual Education Needed for Adolescents in Egyptian Schools.
435 Feldman E (2020) Sex education in Morocco? There is an app for that. In: Reporting Morocco.
436 Morocco World News (2014) New Agreement to Introduce Sex Education in Moroccan Schools. In: Morocco World News.
139
In Bangladesh, school-based SRH programmes are relatively new and have not been extensively
used or evaluated for impact on SRH outcomes. Significant barriers to effective implementation of
school-based programmes included obtaining permission from school management committees
and the MoE for SRH awareness raising activities and curricula given the conservative cultural
context, as well as untrained teachers to deliver the curriculum, the coordinating complexity and
difficulties in linking SRHE with service delivery or referral to health services which limits their
impact on adolescent SRH outcomes. In particular, teachers were not capacitated to effectively
deliver school-based SRH programming437. The broad message of the curriculum is to advocate for
abstinence-only, particularly for women and girls in line with preserving religious morals438.
Table 3: Sexuality Topics Introduced in Bangladeshi Schools in 2012439
Class 6 Class 7 Class 8 Class 9-10
Physical, psychological Physical, psychological AIDS Awareness: Symptoms Physical, behavioral and
changes during puberty sexual abuse and prevention psychological changes
Role of parents during Physical and psychological Early pregnancy: Risk and Coping with mental
puberty wellbeing-ways to protect consequences pressure during puberty
and reaching out for help
Dos and dont's during Reproductive health Reproductive disease
menstruation Addiction: Consequences (Cancer, HIV)
and prevention
Nutritious and balanced Preventing early
diet Early marriages and dowry pregnancy
Peer pressure in Safe motherhood

adolescents-smoking
and alcohol
2. Out-of-school Programmes
Out-of-school programs are critical to reach adolescents outside the educational system. They include
peer education and premarital counselling initiatives as in Box 1.
439 Ainul S, Bajracharya A, Reichenbach L, Gilles K (2017) Adolescents in Bangladesh: A situation analysis of programmatic approaches to sexual and reproductive
health education and services. Population Council
140
Box 1: Peer Education and Premarital Counseling Initiatives
Peer education
Peer educators are volunteers of similar age as the target population trained to deliver SRH information, counseling
and referrals to Youth Health Services to their peers. Peer models are relatively inexpensive, a more sustainable
and easier to implement, as they access existing informal social networks with which adolescents may be more
comfortable discussing culturally sensitive SRH issues. Evidence shows that adolescent peer-led interventions could
be effective in changing knowledge and attitudes. A 2018 systematic review of peer-led sexual health education
interventions in developed countries with mostly low or no responsibility to peers noted improvements in sexual
health knowledge and attitudes in most studies examined; two (2) studies identified improved self-efficacy and
three (3) identified behavioral changes. Meta-analysis revealed a large effect on knowledge change and a medium
effect on attitude change1.
Premarital counselling
A meta-analytic review of evaluating the effectiveness of premarital prevention programs concluded that they are
generally effective in producing immediate and short-term gains in interpersonal skills and overall relationship
quality and these improvements are significantly better than non-intervention couples2. Premarital courses have
been delivered as part of the 2009-12 PEKERTI programme in Malaysia. In Morocco, engaged couples undertake a
compulsory pre-marriage consultation which includes STIs testing for the couple to issue a pre-marriage certificate.
The pre-marital consultation content, scope and informational material is under review3. In Egypt, young people
receive SRH information and services during pre-marital services provided by the Ministry of Health in Youth
Health Counseling Centers4.
1 Sun WH, Miu HYH, Wong CKH, et al (2018) Assessing Participation and Effectiveness of the Peer-Led Approach in Youth Sexual Health Education:
Systematic Review and Meta-Analysis in More Developed Countries. J Sex Res 55:31–44
2 Ainul S, Bajracharya A, Reichenbach L (2016) Adolescents in Bangladesh: Programmatic approaches to sexual and reproductive health education and
services. Situational Analysis Brief. Population Council
2 Carroll JS, Doherty WJ (2003) Evaluating the Effectiveness of Premarital Prevention Programs: A Meta-Analytic Review of Outcome Research.
Family Relations 52:105–118.
3 Morocco World News (2014) New Agreement to Introduce Sex Education in Moroccan Schools. In: Morocco World News.
Malaysia
In Malaysia, several out-of-school educational programmes are being delivered by NPFDB and
FRHAM to address adolescent SRH via information, education and communication (IEC) materials
and adolescent SRH training modules including FP and HIV developed by these agencies. The
NPFDB’s young people programme includes the I Am in Control module providing SRH information
including sexuality, responsibilities, unintended pregnancies, STIs and HIV, abortion and abandoned
babies, techniques/ skills to avoid pre-marital sex and information on safe sex which were adapted
into a training module for young people who participated in the National Services Programmes
according to Malaysian societal values (culture and religion), advocating abstinence only and excluded
141
life-skills such as the use of condoms and other contraceptives. The I Am in Control contains a separate
section on contraceptives for sexually active and high-risk adolescents. There is also an adolescent
centre called KafeTEEN led by NPFDB using a peer educators’ approach focusing on RHSE and supported
by the myKafeTEEN mobile apps for those unable to reach the centres.
The PEKERTI programme for out-of-school programmes target high-risk groups and hot spots areas
and provide capacity building for community leaders and NGOs. Other NPFDB initiatives included
a module designed to enable teachers to implement the programmes in schools after year six (6)
students have sat for their Primary School Examination. An equivalent programme was planned for
the junior high school students upon completion of their Lower Secondary School Examination. The
Training of Teachers module was piloted in over 30 schools, although the evaluation has not been
published440. FRHAM has also advocated for adolescent SRH and rights so that they are empowered
to make informed choices using several empowering approaches implemented by all 13 member
associations across the country including a peer-based approach where young peer educators are
trained to empower their others as well as the electronic version of the Reproductive Health of
Adolescents Module (e-RHAM). FRHAM is also providing SRH and HIV prevention information through
peer education to disadvantaged young people in juvenile homes run by the Department of Social
Welfare441.
Turkey
In Turkey, UNFPA is collaborating with NGOs including the Turkish Family Health and Planning
Foundation to address the SRH rights and needs of the most vulnerable groups. Young people are
being reached via Peer Education Models implemented by NGOs, which effectively respond to the
needs of vulnerable adolescents, including young Syrian refugees, as well as awareness raising efforts
(e.g. theatre-based training) and advocacy for youth-friendly health services (YHS), and to increase
access to SRHE in schools (via SRHE capacitation workshops for teachers and school counsellors), as
well as addressing child marriage and adolescent pregnancy through prevention programmes442.
Egypt
In Egypt, some programmes provide Youth Hotline or websites (shababna.org) for SRH information
services to young people. Most SRHE programmes are offered by international NGOs443.
142
Morocco
The Moroccan government is revising the SRH and FP informational materials and implements several
SRH-related programmes: a young people’s health programmed via Youth Healthcare Centres
(YHCs) (integrating SRH information and services, including contraceptive knowledge and use); a
pre-marital consultation programme; menopause programme and training health professionals
in perinatal care444 . The NGO sector provides several SRH services to vulnerable populations, including
SRH targeted to young people (AMPF NGO); addressing HIV/ AIDS and violence in marginalised
populations such as migrants (ALCS NGO); and providing SRH information and services to health
sex workers, prisoners, gay people, drug users and migrants (OPALS NGO)445.
Bangladesh
Peer education is a common model for adolescent SRH awareness raising in Bangladesh: two-thirds
out of 32 programmes reviewed by the Population Council employed peer-led models. Of the 9
adolescent SRH-focused programmes, 7 employed a peer educator model in combination with other
interventions such as community-based approaches. However, there is limited evidence for the
effectiveness of peer education programmes; rigorous M&E standards should be implemented to peer
education components to ensure their effectiveness in delivering positive impacts for adolescents446.
3. Community-based Interventions
Besides the out-of-school SRHE described above, there are examples of community interventions and
community mobilisation in some of these countries. In Egypt, several NGOs deliver SRH via innovative
community-based programmes or school-based or extracurricular activities outside of the formal
public school system. The Ishraq programme to empower girls and young women in rural Upper Egypt
in Egypt trained peer mentors, worked with parents, informed the community and provided safe spaces
at youth centres to empower girls and young women in rural Upper Egypt447.
Maalouma is Egypt’s first website to provide information on SRH information, as well as online youth
services442. It publishes articles, provides private counselling services through text messaging, and
offers e-learning modules and infographic material as well as other web content on sexuality.
447 Sieverding M, Elbadawy A (2016) Empowering Adolescent Girls in Socially Conservative Settings: Impacts and Lessons Learned from the Ishraq Program in Rural
Upper Egypt. Stud Fam Plann 47:129–144.
448 Zohney, S. (2016). Sexual rights and the internet in Egypt. Mada Masr.
143
Community-based models have been extensively employed in Bangladesh in adolescent SRH
programmes because of their wide reach. Nearly all programmes reviewed by the Population Council
in Bangladesh incorporated some form community-based model to raise awareness about SRH issues,
often in combination with school-based or health facility based-models or with media campaigns.
They deliver SRHE, and sometimes services, along with social services, combined with age-appropriate
recreational activities in common community spaces such as village squares, courtyards or playgrounds,
or via adolescent clubs or youth centres. The Population Council review noted that community-
based models benefit advantaged young people (older, unmarried, literate, and in school), as they
are designed to reach adolescents in general, failing to reach more vulnerable younger, married
and out of school adolescents. Community-based models are also difficult to implement in urban
settings where communities lack social cohesiveness and stability and are highly mobile449.
However, Bangladesh is integrating school-based and community-based approaches.
Two (2) specific community-based interventions deserve special attention – community mobilisation
and social and behavioural communications.
Community mobilization - Community mobilisation targets gatekeepers and decision-makers in

adolescents’ lives (parents, community leaders, religious teachers) to sensitise them on SRH issues
and gain their acceptance and support in implement SRH programming, which is critical for the
programme’s success in conservative contexts. Community mobilisation is a popular approach in
Bangladesh, typically combined with other awareness raising approaches. Community mobilisation
components were identified in all 32 programmes reviewed by the Population Council450. The Egyptian
Family Health Society (EFHS) has been advocating for young people’s SRHE nationwide, convening
several youth and adolescent health conferences in Cairo. The 2011 conference participants
recommended that school curricula be revised to include SRH and life skills for young people. EFHS
followed up on these recommendations with an expert meeting from the upgrading curriculum unit
within the MoE.
A task force was formed with four (4) curriculum experts and four (4) SRH experts to define the health
education and life skills topics to be included in the curricula of the primary, preparatory, and
secondary schools. EFHS organised a workshop for the task force in 2012, and the resulting document
was presented to the Minister of Education451.
144
Social and Behavior Change Communication - Social and Behavior Change Communication (SBCC)
strategies can be used to generate greater public awareness, desensitise SRH issues and generate open
discussion on SRHE and services. A guide was developed for Egypt as in BOX 2, from which Malaysia
can draw some lessons.
Box 2: National Conferences on Youth and Adolescents Health in Egypt
The EFHS convened three (3) National Conferences on Youth and Adolescents Health in Cairo in 2001, 2011
and 2013, bringing together experts from Egypt and overseas, including government, NGOs, with national and
international experts, including government, NGOs, youth representatives to voice their opinions and concerns,
and the media. Participants fully supported the youth’s rights to have information and access to counseling and
services related to their general and reproductive health. The World Programme of Action for Youth to the Year
2000 and Beyond, first adopted by the UN General Assembly in 1995, was used as framework youth-related
organisations. Participants made the following recommendations at the 2011 national conference:
• Review and update school curricula to include health education issues as a basic subject.
• Provide life-skills programs for young people both inside and outside schools.
• Encourage youth-friendly centres to provide services that coincide with needs and expectations of youth,
including premarital reproductive health care.
• Improve the knowledge and skills of those working with young people regarding medical, social, and legal
aspects of youth and adolescent health.
• Include Adolescent Medicine in postgraduate studies in medical and nursing schools.
• Encourage studies and research on youth health and use the findings to shape policies and programs.
• Establish specific youth departments and programs in the different media outlets.
• Use social media to provide health education and life-skills information.
• Identify and replicate successful national, regional, and international experiences after adapting them to suit
local culture.
• Hold the Youth and Adolescents’ Health Conference at regular intervals to monitor progress.
Source: Wahba M, Roudi-Fahimi F (2012) Policy Brief: The Need for Reproductive Health Education in Schools in Egypt. Population Reference Bureau
145
The Islamic Perspective of SRH Education and Gender Roles
Sexuality education remains a controversial issue across selected Muslim countries, and the young
people constituency is largely removed from discourses and policy making around sexuality
resulting in a gap between perceptions and discourses, and current practices. Despite the limited
evidence on how Muslim young people engage in premarital sexual activity, available evidence
highlights a growing tension between norms and young people’s desires and practices452.
The developmental needs of adolescents, including SRHE and services, tend to receive inadequate
attention or be legally constrained. Issues surrounding SRH remain a cultural taboo, especially for
adolescents and young unmarried people453.
Islamic interpretations of the role and status of women in society greatly impact women’s empowerment
in matters of sexuality. Traditional gender roles are pronounced across these predominantly Muslim
countries of mostly Sunni faith, particularly those with high levels of gender inequalities (Egypt,
Morocco and Bangladesh). Despite progressive legislation in Turkey and Morocco, women’s
empowerment remains a challenge across examined countries, and SRHE is very limited due to cultural
and religious contexts that views sex as a taboo. Premarital sexual relationships are prohibited by
Islamic Law and disapproved by society. This translates into limited accessible SRHE and services for
young people, who as a result, face the risk of abuses, STIs and unwanted pregnancies and social
stigmatisation. As seen earlier, all countries examined had higher level polices mentioning SRH.
Morocco has a dedicated National Reproductive Health Strategy which includes adolescent’s
knowledge of SRH, STIs and contraception as focused areas, and notes that sexuality education is
to be delivered in secondary and tertiary educational institutions covering FP methods, although no
information was found regarding the curriculum, and other sources indicated that CSE is not being
delivered in educational institutions. Both Malaysia and Bangladesh have a dedicated national
strategy for adolescent health containing SRH components, and Malaysia has a National Adolescent
Health Plan of Action to further operationalise the strategy, with SRH being one (1) of the priority
areas. In Egypt, the role of education is emphasised in both population and SRH strategies, although
the implementation is yet to occur. The Turkish 2013-17 National Strategic Health Plan included
raising awareness of reproductive health and encourage healthy behaviours as an objective to
be achieved.
146
A conservative social environment, lack of political will and limited multisectoral coordination
were identified as key barriers to implementing RHSE in Malaysia454, Turkey455 and Egypt456. SRHE
remains a controversial topic across these countries, and if delivered within national curriculums
in school-based programmes, the approach used is an abstinence-only until marriage approach.
The content is limited to reproductive health information, promoting abstinence-only to curb what
is perceived as moral transgressions such as premarital sex and its consequences, and excludes
information on safer sex and contraception. This is despite existing evidence from systematic review
and meta-data analyses indicating that CSE is a more effective approach over abstinence-only
or abstinence plus programmes in delaying sexual initiation and reducing the negative health
consequences of unprotected sex. In Malaysia, community misconceptions about CSE seem to
disproportionately affect girls, particularly Malay girls, who seem to have less access to RHSE and
services457.
Knowledge of SRH Among Adolescents
The basic premise here is inadequate levels of knowledge is the overwhelming reason for RHSE, and
adequate levels of knowledge and skills are assumed to be the direct outcome RHSE that is CSE carried
out effectively. Reproductive rights and sexual discourse are still taboo topics across these countries,
resulting in limited SRH knowledge among young people. In Malaysia, the 2014 Malaysian Population
and Family Survey (MPFS) revealed that SRH knowledge among 13-24 years is very limited. Only about
half of those aged 13-17 years could locate reproductive organs, 73% knew that diseases could be
sexually transmitted although they had low knowledge of symptoms (23% for males; 18% for females);
34% knew that pregnancy could occur in the first sexual intercourse; 33% knew condoms prevent STIs;
45% of young people had contraceptive knowledge (38% in those aged 13-17 years and 54% in those
aged 18-24 years), condoms (82%) and the pill (61%) being the most known; 35% were exposed to
pornography (61% obtained it from the internet) and 4.8% engaged in sexual intercourse (2% in the
13-17 years; 8% in the 18-24 years), with only 35% having used contraceptives, revealing that
Malaysian young people are engaging in premarital sex without protection. About half had a
girlfriend/boyfriend; 21% kissed; 13% touched sexually; 20% masturbate; 3% used telephone
sex; and 2% used cybersex458.
456 El-Hameed D (2015) Sexuality Education: Egypt’s Missed Opportunity. In: TIMEP.
457 Wong LP (2012) An exploration of knowledge, attitudes and behaviours of young multiethnic Muslim-majority society in Malaysia in relation to reproductive and
458 premarital sexual practices. BMC Public Health 12:865.
NPFDB (2016) Fifth Malaysian Population and Family Survey 2014 - Report on Key findings
147
Turkey’s young people (accounting for about one-third of the population) is exposed to
misconceptions regarding sex and sexuality. Most studies consistently demonstrated that
adolescents have important information deficiencies about reproduction health and sexuality. The
1999-03 Project of Change in Adolescence, conducted for 814,177 students in 2670 schools by the
MoE revealed that half of the 6th, 7th and 8th grade students had not heard about the opposite sex’s
reproductive organs and 70% of male students did not know where the baby develops459. A Turkish
study of 600 elementary school students noted 82% were aware of the changes in their own bodies,
and 69% had knowledge about the place and the functions of their reproductive organs. Only 55%
had knowledge about puberty, and girls attained this knowledge mostly from their mothers (78%),
whereas 25% of boys attained it from the media460. Several studies concluded that a sexually
active adolescent group exists despite the lack of sexuality education461. There are culture-specific
and gender-dependent differences in sexual attitudes and behaviours of university students. A study
of Turkish university students (20-25 years) revealed that male students engage in more sexually risky
behaviours. Although most male students opposed premarital sexual intercourse, the frequency of
sexual intercourse among male students (61%) was higher than among female students (18%), and the
mean age of first sexual intercourse was lower, with 47% using condoms at first sexual intercourse462.
Available evidence highlights a gap between Egyptian norms and perceptions and young people’s
desires and practices. Young people aged 15-24 constitute about one-quarter of the population in
Egypt. Egyptian young people receive very limited to none SRHE through the formal school system.
Both national and subnational surveys reveal young Egyptians lack basic information on SRH topics
and consult misleading or inaccurate sources463. About 54% of all Survey of Young People in Egypt
(SYPE) respondents aged 13-35 in 2014 had heard of STIs (60% boys; 48% girls). Of those, 73%
had heard of HIV/AIDS and knowledge increased with age, wealth, education and urban areas. Young
people, especially women, have limited knowledge about HIV or its modes of transmission.
About 61.5% of all respondents aged 13-35 (both married and unmarried) knew of contraceptive
methods (71.5% of all female, 52% of male). Knowledge increased with age, urban setting and marital
status)464.
460 Yazıcı S, Dolgun G, Öztürk Y, Yilmaz F (2011) The Level of Knowledge and Behavior of Adolescent Male and Female Students in Turkey on the Matter of
Reproductive Health. Sex Disabil 29:217–227.
461 Bikmaz FH, Guler DS (2007) An Evaluation of Health and Sexuality Education in Turkish Elementary School Curricula. Sex Education: Sexuality, Society
and Learning 7:277–292
462 Aras S, Orcin E, Ozan S, Semin S (2007) Sexual behaviours and contraception among university students in Turkey. J Biosoc Sci 39:121–135.
464 Population Council (2014) Survey of Young People in Egypt
148
Box 3: The longitudinal Survey of Young People in Egypt (SYPE)
The longitudinal Survey of Young People in Egypt (SYPE), involving a nationally representative sample of 15,000
young people age 10-29 from 11,000 households in 2009, of which 10,000 followed up in 2014 (a group
aged 13-35 then), is a landmark survey conducted by the Population Council and Egypt Poverty, Gender and
Youth Program, offering gender-disaggregated information on SRH, schooling, civic engagement, employment,
and other topics. This survey collected SRH attitudes, beliefs and behaviours and practices from youth
regardless of their married status, which is critical to estimate unmet need for contraception and other
SRH services. Results were used to inform youth’s government policies, including the Population Council’s
pioneering programs, Ishraq and Neqdar Nasharek, to empower girls and young women in rural Upper Egypt.
Source: Population Council (2015) Panel Survey of Young People in Egypt (SYPE).
Bangladeshi adolescents face high rates of early marriage, high fertility rates, limited negotiation skills,
and insufficient awareness of -and information about- reproductive health465. Although extramarital
sex is forbidden, studies reveal diverse sexual practices and behaviours practised both within and
outside marriage, particularly among the young people, and their lack of adequate SRH information
and services often lead to risky behaviours466.
Barriers to Implementing Sexual and Reproductive Health Education
Several Malaysian studies have assessed the existing PEERS curriculum for SRHE and identified several
critical problems related to its content and delivery methods and propose several recommendations
to overcome them (summarised in Appendix 2). While the existing PEERS curriculum for RHSE has
expanded its key elements over the years, it remains an abstinence-based curriculum that does
not align with UNESCO’s CSE guidelines (focusing on the reproductive system and delivered in a
fragmented way across several subjects, teachers lack the training and ongoing support, thus they feel
uncomfortable delivering the content. Parents are not engaged in the learning process, and students’
knowledge of SRH is limited. There is a lack of institution al coordination at all levels and limited
M&E mechanisms467.
In Turkey, long-standing challenges to implementing SRHE include a lack of a national multisectoral

young people policy, inadequate information on SRH and CSE in school-based curricula, lack of
YHS and conservative environment468.
465 Ainul S, Bajracharya A, Reichenbach L, Gilles K (2017) Adolescents in Bangladesh: A situation analysis of programmatic approaches to sexual and reproductive
health education and services. Population Council
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The Egyptian Government is failing to provide CSE to young people due to societal resistance and
a lack of political will469. As of 2015, a network of local NGOs provides SRHE to boys and girls aged
15-17 backed by the National Council for Childhood and Motherhood, with support from UNFPA
and UNICEF470.
In all five (5) countries, Islamic precepts and cultural norms pose as challenges to RHSE especially CSE,
in both policy and programme level, with negative perceptions and misconceptions of the public
leading to its poor acceptance. Overcoming religious and cultural barriers require stronger and
more inclusive coalitions and social mobilisation (including youth-led organisations) for SRH
at the local, regional and national levels. Evidence from Bangladesh indicate opportunities for
people-centred advocacy at all levels of governance. Another entry point for advocacy includes
increasing accountability via monitoring legal and policy developments, making budgetary
allocations for CSE and establishing mechanisms to increase civil society engagement471.
There are several reasons for the lack of monitoring and evaluation (M&E), including religious
censorship and misconceptions. A scoping of the impact of adolescent SRH programming in LMICs
conducted by the International Initiative for Impact Evaluation concluded that very few studies
explored the impact of adolescent SRHE programming in Muslim countries472. In this review, the
information could only be obtained for Malaysia, Morocco and Bangladesh.
Malaysia
The evaluation of the SRHE programmes under the 2013-2017 Country Programme Action Plan (CPAP)
was sponsored and undertaken by UNFPA in 2017473. This noted several challenges, including
the difficulties in measuring progress due to lack of baseline measures, short implementation time,
limited coordination among key stakeholders, inconsistent methods for M&E at all levels and limited
funding to implement the programme.
Recommendations included: a review of the PEKERTI policy; improve the M&E mechanisms; improve
capacity building and research; ensure implementation of the policy across age groups; engage
people, public and private sectors, and review the FP policy accounting for the needs of sexually active
and unmarried demographics.
469 El-Hameed D (2015) Sexuality Education: Egypt’s Missed Opportunity. In: TIMEP.
472 International Initiative for Impact Evaluation (3ie), Rankin K, Heard A, et al (2017) Adolescent sexual and reproductive health: scoping the impact of programming
in low- and middle-income countries. International Initiative for Impact Evaluation (3ie)
473 Lembaga Penduduk dan Pembangunan Keluarga Negara (2017) UNFPA-NPFDB Final Project Evaluation Report (MYS4U604): research and Module Development
on SRH for Young People 2017, Kuala Lumpur, Malaysia
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An evaluation of the overall 2009-12 PEKERTI’s PoA conducted by NPFDB and MWFCD474 also in
2017. It revealed the weak implementation of PEKERTI, recommending a comprehensive revision
to urgently address the RHSE and services needs of Malaysians. Several challenges were identified,
including a lack of baseline indicators to measure programmatic outcomes, with the existing outcomes
not clearly defined; the four-year life cycle on the PEKERTI (2009-12) was not sufficiently long to
monitor trends and progress, with limited coordination across relevant ministries and agencies
resulting in challenges with standardising M&E methods across implementing agencies, and inadequate
financial resources to implement new interventions and expand existing ones. Regarding the specific
components of the 2009-12 PEKERTI’s PoA, the evaluation noted that Advocacy met 83.3%
of its targets; Capacity Building 66.7%; Research & Development 33.3%; and M&E 100% (this
was limited to two (2) outcomes; the establishment of an M&E committee, and the establishment
of a technical working committee, with no other measurable indicators).
The evaluation recommended to review the PEKERTI policy and PoA and make it more outcome-
friendly; to develop a more systematic and structured M&E mechanism by establishing technical
working and steering committees; strengthen the human resources capacity development and
programme research and development, given the weak evaluation outcomes; ensure the policy
covers all age demographics, and not only adolescents and young people; encourage people,
public and private (3Ps) partnership in its implementation; review the FP Strategy, accounting for
the unmet SRH needs of those under 18 years and unmarried who are sexually active, particularly
in legal terms; and consider the complexity and sensitivity of SHRE from a human rights, ethical,
religious, health and socio-cultural aspects. In conclusion, M&E activities have been very limited,
and the evaluation recommended an urgent review of the PEKERTI Policy and PoA.
A 2019 review of Malaysia’s progress regarding CEDAW475 noted that sex education is inadequate
and based on religious morals rather than a rights-based approach to bodily integrity. The sex
education curriculum for schools was approved by Cabinet in 2006 but has yet to be fully
implemented.
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Bangladesh
In Bangladesh, initiatives to address adolescent SRH have been implemented at different times by
the Government and NGOs, but activities have often been fragmented and are not well documented
or evaluated, making it difficult to know what worked well and what did not. Most programmes
conducted a qualitative assessment at baseline to highlight success stories but did not apply rigorous
impact evaluation to assess the impact of the interventions (a weakness of qualitative studies).
Moreover, programmes documentation was not based on monitoring data, and the implementation
process and lessons learned were rarely documented. The Population Council’s recommendations
for implementing adolescent SRHE and services in Bangladesh are noted in BOX 4476.
Box 4: Population Council’s recommendations for implementing SRHE and services in Bangladesh
The Population Council review noted the following recommendations for implementing adolescent SRHE and
services:
• Employ multifaceted programs, combining culturally sensitive SRHE with more acceptable programs targeting
livelihoods, empowerment, maternal health or child marriage
• Expand the number of interventions that specifically target vulnerable demographics, including younger
adolescents, unmarried girls, and underserved groups such as boys and urban adolescents.
• Encourage age-appropriate intervention design, through innovative and participatory approaches (story-telling,
art-centric and psychosocial approaches, the use of interactive, ICT-based curricula and life skills development,
or sports-based programming for young adolescents) to address underrepresented needs of adolescents.
• Strengthen the rigor of monitoring, evaluation and research designs to evaluate current interventions
and create a culture of evidence-based programming and policymaking.
• Support the sustainability of Bangladesh’s Government in leading the SRH coordination efforts with
implementing partners to avoid duplication and fragmented programming and ensure the most efficient use
of resources.
Source: Ainul S, Bajracharya A, Reichenbach L (2016) Adolescents in Bangladesh: Programmatic approaches to sexual and reproductive health
education and services. Situational Analysis Brief. Population Council
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Morocco
Morocco’s evaluation of the2011-20 National Reproductive Health Strategy based on interviews with
key informants identified the following implementation barriers: limited coordination and integration
of the various SRH services, lack of awareness of the strategy by healthcare professionals; limited
and fragmented statistical capacity, which impacts on its monitoring; difficulties in centralising
the strategy because of long-standing specialised programmes addressing aspects of SRH such as
the FP programme; lack of funding to fully implement the strategy (and a need to collaborate with
international organisations to support the costs of implementing it); lack of experienced
medical professionals in certain regions; and lack of an action plan before implementing the
strategy477. The recommendation for this evaluation is presented in (BOX 5).
Box 5: Evaluation of the Moroccan 2011-20 National Reproductive Health Strategy
The evaluation of the Moroccan 2011-20 National Reproductive Health Strategy based on interviews with key
informants provided the following recommendations:
• Improve coordination of actors and institutions in the areas of reproductive health
• Educational programmes on various SRH topics have been implemented separately (on STIs, maternal health)
but there is a need to integrate the overall SRH educational programme
• Evaluate the level of knowledge of health professionals before designing the educational plan and capacitate
health professionals in gender principles and SRH issues (obstetrics, nurses and doctors) and medical students
by integrating a SRH module in medicine faculties
• Community engagement in gender and SRH training
• Conduct SRH research:
1) identify barriers to integration of SRHE and services;
2) include all women in reproductive age, not only married women in future surveys;
3) conduct a cost-benefit analysis on implementing SRHE and servicers versus not implementing it
4) identify the impact of improved SRH services on unwanted pregnancies; and
5) identify the savings that investing in women and children's have on productivity, education and the economy
• Increase the effectiveness of SRH communication campaigns (materials and content) targeted to the general
public.
Source: Abaacrouche, M & UNFPA’s technical support (2020) 2011-20 Evaluation of the National Reproductive Health Strategy
477 Abaacrouche, M & UNFPA’s technical support (2020) Evaluation of the National Reproductive Health Strategy 2011-2020
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DISCUSSION
Preparing children and adolescents for the transition to adulthood, where safe sexual and reproductive
behaviours and choices are understood and practised remains a priority for all governments. This desk
review is based on published policy documents, research papers and reports and well as stakeholder
consultations (including the TWC) and presents insights across selected Muslim countries.
Turkey and Malaysia are both upper middle-income countries and have higher human development
compared with the low middle-income countries of Egypt, Morocco and Bangladesh. Both Egypt and
Bangladesh are experiencing high fertility and quick population growth amidst limited resources
and wide differentials in SRH access (urban vs rural), thus they are applying a population control
strategy. Conversely, Malaysia and Turkey introduced contraception a few decades ago to control
population growth with resulting reductions in fertility below replacement level and are now shifting
their population policies to encourage higher fertility and population growth.
The findings from this review can be discussed from three (3) broad aspects including the Islamic
perspective as a critical determinant of SRHE in Muslim countries, the extent in which SRHE is being
conducted in these five (5) countries (it is variable but generally limited) and the need to link SRHE
with SRH services.
Islamic Perspective of SRH Education
The findings of several previous studies across Muslim countries indicate a strong influence of religion
on gender roles, sexuality and level of provision of SRHE and SRH services. The Sunni Muslim faith
plays an important role in the acceptance of SRHE and the extent to which governments are able
or willing to promulgate laws and policies that regulate SRH and SRHE. Governments tend to
approach sensitive issues using less confronting and more socially acceptable means, such as the use
of terminology. In Malaysia, the term used in PEKERTI is “Reproductive Health and Social Education”
avoiding the use of “sexual”. Also, the term “termination of pregnancy” (as used by MoH guidelines)
is used instead of “abortion” which is the term used in the Civil Law.
Indeed abortion provides a good example of the role of religion in SRH. Needless to say, the ruling
on abortion differs between Muslims non-Muslims. For all Malaysian women (Muslims and non-
Muslims) abortion is provided by the Penal Code (Sections 312 – 316). Compared to many other
countries, these provisions can be viewed as less restrictive; any medical practitioner may carry out
an abortion on a woman on the grounds that continuing with the pregnancy will threaten her life,
physical health and mental well-being. For Muslims, additionally, there is a fatwa.
This rules that abortion is allowed but discouraged (makruh) with no condition within 40 days of
pregnancy; allowed (harus) between 40 and 120 days if the pregnancy threatens the life of the mother
and the foetus; and not allowed (haram) after 120 days.
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Despite the endorsement of the 1994 ICPD (which crafted the definitions of reproductive health,
reproductive rights, sexual health, and sexual rights) by these countries, they are yet to fulfil all
commitments made in the ICPD’s Programme of Action (PoA). This PoA is reviewed every 5 years; he
latest ICPD commitments (after 25 years) were made in Nairobi in November 2019, where a specific
call for action on CSE was made.
These five (5) Sunni Muslim countries differ in the manner and the extent of implementing SRHE, and
this is attributed to historical, sociocultural, and geopolitical differences. For instance, Turkey became
a republic following the fall of the Ottoman empire, making it less conservative in its current practice
of Islam. The differences in the four (4) madhabs of schools of thought of Sunni Islam– Hanafi,
Maliki, Shafie and Hanbali– which guides the practices of the Muslims communities is also a factor for
these differences. The majority of the population in Bangladesh and Turkey belong to the Hanafi
mazhab; while Morocco is mostly of Maliki thought. Egypt mostly observes the Shafie school of
thought, although there are followers of Hanafi and Maliki. In Malaysia, the Muslim community are
overwhelmingly of the Shafie school of thought.
Several articles address the topic of sex education and Islam, such as the one (1) by Ermayani478
who highlights the role of parents as primary educators in the family, followed by other teachers
(including religious teachers, community leaders, and scholars). Ermayani concludes that “the role of
educators is very urgent to socialize the understanding that sex education in an Islamic perspective
so that parents and the community understand sex education is not limited to the guidance of
knowledge about the reproduction of men and women.”
It is undeniable that the Islamic world is undergoing a transformation in its sexual discourse and
needs to incorporate a more progressive perspective of how sexuality, reproductive rights and women’s
rights fit into society. The ability of any woman to determine her own reproductive destiny is directly
linked to not only individual choice but her environment and the broader community. A woman
cannot make an individual decision about her body if she belongs to a community that provides
inaccurate or incomplete SRHE or services479.
Public health concerns across these countries regarding the consequences of premarital and
unprotected sex, which disproportionately affect girls and women compared to boys and men
(including unwanted pregnancy, unsafe abortion and baby abandonment, and STIs), indicate the urgent
need to incorporate a girls’ empowerment component within the SRHE curriculum480.
478 Ermayani, T (2019) Sex education an early age in the perspective of Islam, Proceedings of the 2nd International Conference on Education, ICE 2019,
27-28 September 2019, Universitas Muhammadiyah Purworejo, Indonesia
479 Tabahi S (2020) The Construction and Reconstruction of Sexuality in the Arab World: An Examination of Sexual Discourse, Women’s Writing and
Reproductive Justice. Sexuality & Culture.
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SRH Education Programmes
Schools provide the ideal setting for sexuality education, as most children, adolescents and young
people are enrolled within the educational system. While there is some form of school-based SRHE
in these countries, they vary considerably at both policy and programme levels. Religious influences
seem a significant barrier for governments to formulate policies, and to introduce sex education in
schools; and where SRHE is conducted in schools, there are several constraints. Malaysia is leading,
including age-appropriate RHSE – it starts from early primary classes. While no evaluations of school-
based education programs have been carried out (except Turkey which concluded that topics such
as unintended pregnancy, changes in adolescence, sexual violence and abuse, birth control and
sexual discrimination were absent481), reports indicate that the curriculums are either not being
implemented or being poorly implemented due to teachers’ reluctance to teach SRHE. Teachers are
uncomfortable teaching SRH-related information as they are not capacitated to effectively teach.
Students are often asked to read these chapters on their own, and parents are not engaged in the
learning process.
Efforts should be directed towards better aligning the curriculum with CSE principles and guidelines
by including information on safer sex and contraception as well as rights, participation, gender
equality and power, and positive sexualities and respectful relations. The eight basic concepts
outlined by the ITGSE should be considered when developing the national curriculum, which
should be designed based on local context and/or existing standard and frameworks. SRHE should
be age-appropriate and commence as early as possible (preferably from age 5)482.
It is also critical to sensitise, train and support teachers, parents and community and religious leaders
to ensure the effective implementation of the curriculum. WHO provides an overview of educators’
competencies (attitudes, skills and knowledge) for delivering CSE483.
A whole-school approach has been effective in delivering high-quality CSE by actively engaging
teachers, parents, and community and progressive religious leaders in developing and delivering
the CSE curricula and building community and service delivery partnerships, combined with
participatory teaching within a gender and power relations framework484.
Very little evaluation has been carried out, and few programs have been scaled up. However, some
important insights can be obtained from pilot projects – many of these favour participatory approaches
to teaching and parents’ involvement.
482 UNESCO (2018) International Technical Guidance on Sexuality Education (ITGSE)
Education (BZgA).
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The 2010-12 SRHE pilot by the Egyptian Family Society and the MoE involved young male and female
physicians trained in communication and participatory approaches to deliver at seminars on health
topics of interest to adolescents, which resulted in their improved SRH knowledge. Importantly,
students shared learned information with their networks. Both students and parents consider
physicians a more acceptable source of information than teachers. Another school programme in
Turkey adapted CSE guidelines adapted to the local context and was piloted in 2007 for secondary
school students with interactive sessions and involving parents. It generated positive results. In
Bangladesh, school-based SRHE programmes are relatively new and have not been extensively
used or evaluated for impact. Significant barriers to effective implementation have been identified;
in particular, teachers were not capacitated to effectively deliver the curriculum485.
Out-of-school programs are critical to reach adolescents outside the educational system. These
services were limited across these five countries, with poor uptake by adolescents and young people
due to stigma or lack of awareness, particularly in rural areas. In Malaysia, several out-of-school
SRH educational programmes are delivered by NPFDB and FRHAM, with limited coverage and uptake.
In Egypt and Bangladesh, most SRHE programs are offered by international NGOs pioneering youth
SRH programmes, although very few have been scaled up. Community-based SRH programs have
been extensively employed in Bangladesh due to their wide reach, delivering SRHE and some services
along with recreational activities in community spaces.
In Turkey, UNFPA is collaborating with NGOs (the Turkish Family Health and Planning Foundation),
to address the SRH rights and needs of the most vulnerable groups via Peer Education Models, as well
as awareness raising efforts (e.g. theatre-based training) and advocacy for Youth-friendly Health
Services486. In Morocco, YHCs integrate SRH information and services, including contraceptive
knowledge and use.
While SRHE programs are set either in schools or in communities, there is increased use of integrated
approaches that work both in schools and communities, taking advantages of the strengths of both
models. Bangladesh particularly benefits from this integration, as there are low levels of secondary
and tertiary education enrolment.
Premarital counselling programmes are generally effective in producing immediate and short-term
gains in interpersonal skills and overall relationship quality487, but not effective in preventing most
adolescent pregnancies and HIV/STIs among young people. These programmes include SRH
information and services are being offered in Malaysia, Egypt (by MoH via youth-friendly health
centres, known as Youth Health Services in Malaysia) and Morocco, where engaged Moroccan couples
undergo a compulsory premarital consultation including STIs testing.
487 Carroll JS, Doherty WJ (2003) Evaluating the Effectiveness of Premarital Prevention Programs: A Meta-Analytic Review of Outcome Research. Family Relations 52:105–118.
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Peer education programmes are relatively inexpensive, sustainable, easier to implement and can
access existing informal social networks where adolescents may feel comfortable discussing culturally
sensitive SRH issues. Evidence indicates that adolescent peer-led interventions could be effective in
changing knowledge and attitudes but less so in changing behaviours. Peer education programmes
are being implemented by NGOs in Malaysia, Turkey, Egypt and Bangladesh. In Malaysia, FRHAM is
training young peer educators with SRH and HIV prevention information among disadvantaged young
people. The Turkish Family Health and Planning Foundation is addressing the SRH rights and needs
of the most vulnerable groups via Peer Education Models. The Egyptian Family Planning Association
provides IEC programmes for the general public, many of which (particularly amongst young people)
are run on a peer-to-peer basis488. Peer education models are commonly used in Bangladesh, combined
with other interventions. However, rigorous M&E standards should be implemented to peer education
components to ensure their effectiveness in delivering positive impacts for adolescents489.
Community mobilisation aims to raise awareness in the community targeting gatekeepers and
decision-makers in adolescents’ lives (parents, community leaders, religious teachers) and is critical for
programme success in conservative contexts. While the review did identify information across all
examined countries, there are fairly good findings from Bangladesh, and to a lesser extent from Egypt.
Community mobilisation is a popular approach in Bangladesh, typically combined with other awareness
raising approaches490. The EFHS has been advocating for young people SRHE nationwide, convening
several health conferences in Cairo involving the media491. When designing an SBCC plan for Malaysia, it
might be beneficial to refer to the SBCC guide to designing SRH programs for young people in Egypt492.
As pointed out earlier, the level of knowledge of children and adolescents on SRH is both a rationale for
SRHE (low knowledge) and an outcome of SRHE (improved knowledge). The findings show great
similarity – in all countries, there is inadequate SRH knowledge, thus strengthening the argument
for a more effective SRHE in all these countries. Young people who lack the needed knowledge are
likely to engage in unhealthy sexual behaviours and seek SRH related information from unreliable
sources, mainly from friends and increasingly from the internet.
Common barriers to SRHE across countries were expected – these include unclear (or lack of) policy,
unclear and/or inadequate curriculum, low levels of knowledge among school teachers who lack
training, and experience discomfort and unwillingness to teach a culturally and religiously sensitive
subject. These challenges require effective strategies for overcoming them. The most urgent and more
difficult to be addressed are the weak political will and societal resistance.
488 IPPF (2016) Egyptian Family Planning Association

492 Johns Hopkins Center for Communication Programs (2017) Social and Behavior Change Communication: Guide to Designing Sexual and Reproductive Health
Programs for Youth in Egypt
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M&E of SRHE is weak in all countries. Interventions across examined countries were implemented at
different times by the Government and NGOs, but activities have often been fragmented and are not
well documented or evaluated, making it difficult to know what worked well and what did not. There
was a lack of robust M&E mechanisms in all countries. Information on M&E of SRHE was available only
from three (3) countries – Malaysia, Bangladesh and Morocco, which had carried out an evaluation. In
these three countries, the evaluation made several recommendations which include strengthening
(3) existing SRHE programmes in terms of content and approach, improving inter-sectoral and inter-
agency coordination and community engagement, and ensuring the sustainability of the programmes.
The evaluation of PEKERTI PoA carried out by NPFDB and MWFCD493 in 2017 identified the problem
of weak implementation, particularly in two (2) areas, which were not unexpected – Capacity Building
and Research and Development.
Linking SRH Education and SRH Programmes and Services
It is critical that SRHE and services are integrated for maximum impact. In the countries reviewed,
coverage and uptake of youth-friendly services are poor, which requires awareness raising among
adolescents’ teachers and guardians. Furthermore, health care providers should be capacitated
to deliver SRH information and confidential, non-judgmental and non-discriminatory services to
both married and unmarried demographics. Malaysia started the provision of universal access to
SRH services for all adolescents in primary, secondary and tertiary healthcare facilities nationwide
in 2012, and the MoH led initiatives to provide SRH services for married and unmarried adolescents
via the 2012 Guidelines on Managing Adolescents Sexual and Reproductive Health Issues in Health
Clinics to support Youth Health Services. Despite the availability of these services, there is poor
uptake due to fear of stigmatization or lack of knowledge about their existence494.
In Morocco, the public sector provides multidisciplinary services, including SRH information and
services (contraceptive knowledge and use), via YHCs targeting young people. However, uptake among
young people is poor, and efforts are underway to promote these centres to adolescents by linking
them with other activities delivered by the ministries of youth, sports and education.
Although pilot government and non-government youth-friendly clinics were established in Egypt,
their coverage and use remain limited, with most beneficiaries being married women, highlighting
the need to address cultural and religious sensitivities495. Turkey is experiencing a lack of YHS within
a conservative environment496. Adolescent friendly health centres in Bangladesh focus on improving
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access to SRH information, counselling and clinical services within the existing general health care
facilities (which may reduce the stigma experienced by unmarried girls), although uptake is poor.
Also, both clinical or non-clinical services were found to have lack integration of SRH issues, and
clinical SRH services tend to only be delivered to married adolescents497.
The above observations have several implications. For instance, multisectoral agreements over the
content and delivery methods and its integration into a government’s healthcare priorities should
ensure a minimum standard of SRHE and corresponding health services that leave no one (1) behind.
A multilevel approach addressing individuals, networks and communities at national, regional and local
levels can support the implementation and scale-up of CSE programmes, address conservative
opposition, advance international cooperation, and adapt innovation in content, delivery and
methodological research.
Finally, it is noteworthy that for Malaysia, the 2009-2012 PEKERTI is both a Policy and a PoA, contained
in the same document. The request for recommendations was for the PoA only; a Policy normally covers
a longer period than a PoA. It is also a common practice to first promulgate a National Policy, followed
by a National Strategic Plan (covering 5 to 10 years) outlining broad principles and strategies, and a
subsequent PoA (sometimes referred to as Operational Plans) covering shorter timeframes (either one
or two years) within the lifespan of the Strategic Plan. These plans are more detailed with activities
to achieve each of the broad strategies within the Strategic Plan, and the roles and responsibilities
of implementing agencies are clearly stated for each activity. The NPFDB may wish to explore
this approach.
LIMITATION
This review faced several challenges, including limited time and resources. The published information
on SRHE across selected countries was also limited. For instance, SRH related policies and action
plans might not have been published by governments, in which case, secondary data sources referring
to these policies were used. In addition, policies were written in languages other than English. In
addition, information about SRHE across examined countries was limited to children, adolescents
and young people and not much information was found across other age groups.
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CONCLUSION
Overall, this desk review has achieved it objective of generating evidence related to the
implementation of RHSE in Malaysia and four (4) comparative Muslim countries, that will contribute
to the review and update of PEKERTI (2009-2012) to develop PEKERTI 2020-2024).
Specifically, from the findings and the discussion above, the following conclusions are made:
1. From the 2017 evaluation of PEKERTI, and a 2019 review of Malaysia’s progress regarding CEDAW
commitments498 it is noted that sex education is inadequate and that it is based on religious
precepts rather than a rights-based approach. Notwithstanding this, Malaysia is taking a proactive
approach to improve RHSE and SRH services, as demonstrated by this desk review through a
multisectoral consultative process that provides the opportunity to design, implement and
monitor a more inclusive, comprehensive, engaging and effective RHSE programme that
meets the needs of Malaysia’s multiracial and multifaith society, and improves integration
of RHSE and SRH services, but it requires strong leadership and well-trained teachers and
health professionals on CSE principles.
2. School-based RHSE programmes are cost-effective in reaching children, adolescents and young
people since most are engaged in education. Community-based out-reach interventions are
equally important in transforming harmful attitudes, beliefs and behaviours and ensuring acces
to SRH information and services for most vulnerable groups, including out-of-school
adolescents499. Although components of CSE are being integrated within Malaysia’s school
system, a significant gap remains in content and delivery which needs to be addressed via
curriculum revision, teachers training and delivery methods to improve information retention
and provide effective RHSE, as noted by the 2017 evaluation of the PEKERTI programme500.
The programmes should be contextualised to address specific adolescent health needs,
linked to SRH services, and monitored and evaluated over time to identify and scale-up
successful interventions and course-correct or terminate unsuccessful ones for the best
allocation of limited resources. Multisectoral agreements over the content and delivery methods
and its integration into a government’s healthcare priorities should ensure a minimum standard
of RHSE and health services that leave no one (1) behind.
499 Vanwesenbeeck I (2020) Comprehensive Sexuality Education. In: Oxford Research Encyclopedia of Global Public Health. Oxford University Press
500 Lembaga Penduduk dan Pembangunan Keluarga Negara (2017) UNFPA-NPFDB Final Project Evaluation Report (MYS4U604): research and Module Development
on SRH for Young People 2017, Kuala Lumpur, Malaysia
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A multilevel approach addressing individuals, networks and communities at national, regional
and local levels can support the implementation and scale-up of RHSE programmes, address
conservative opposition, advance international cooperation, and adapt innovation in content,
delivery and methodological research.
3. The findings from the comparative study of countries provide important insights to inform
Malaysia’s 2020-24 PEKERTI, which aims to overcome challenges and enhance the effectiveness
of comprehensive and age-appropriate RHSE in formal and informal settings. Likewise, these
countries can learn from Malaysia’s experiences. The recommendations that follow can support
the fulfilment of Malaysia’s commitment to implementing the PEKERTI’s PoA by not later than 2021
as part of the ICPD Programme of Action and the 2030 SDG Agenda501. Achieving the health,
education and gender equality SDGs by 2030 will generate benefits beyond SRH and across
other interconnected SGDs, but it depends on how seriously key stakeholders (governments
and implementing partners) take the specific SRHR targets and fully implement relevant
policies, services and programs to enhance the health and lives of populations and particularly,
vulnerable demographics502.
501 Malaysian Government (2019) Accelerating Malaysia’s Progress Towards Implementation of ICPD Programme of Action. In: Nairobi Summit.
502 Guttmacher Institute (2015) Onward to 2030: Sexual and Reproductive Health and Rights in the Context of the Sustainable Development Goals. In: Guttmacher
Institute.
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RECOMMENDATION
This review proposes a comprehensive, multilevel approach aligned with socio-ecological frameworks
based on UNFPA’s CSE principles and guidelines, which is likely to be most effective in addressing
the identified barriers by targeting adolescents; gatekeepers and decision-makers in adolescents’
lives (parents, teachers, community leaders and religious teachers); and policies and services. A more
detailed presentation of recommendations is in Appendix 4. In summary, the recommendations are:
1. Revive the ACCRH, overseen by NPFDB, which will look into the improvement of the quality of
SRHE by improving multisectoral collaboration and coordination (involving governmental, NGO
and private partnerships), ensuring participatory planning and effective monitoring and overseeing
the implementation of the 2020-24 PEKERTI’s PoA across all age groups (commencing from
age 5), and ensuring that SRHE is fully integrated into SRH services and programmes.
2. Improve the RHSE curriculum and programmes by allocating adequate financial resources, including
personnel to build the capacity of SRH service providers and SRHE educators. Reframe RHSE as a
health issue (e.g. family health) linked to international commitments (achieving the SDGs,
ICPD-PoA, Beijing Declaration and CEDAW) appealing to contextual values and beliefs while
ensuring the adaptation of right-based and gender-focused principles to Malaysia’s multiracial
and multifaith society by:
i. Adapt the school-based CSE curriculum guidelines and empower children (defined as aged
0-18)503, adolescents (defined as aged 10-19) and young people (defined as aged 10-24)
in making informed decisions by integrating four (4) key components including rights,
participation and agency; SRH and behaviours; gender equality and power; and positive
sexuality and respectful relations504.
ii. Integrate CSE training in the teachers’ syllabus and improve training modules using a
participatory teaching approach with follow up and support.
503 According to the following sources

• OHCHR (1989) Convention on the Rights of the Child
• The Commissioner of Law revision, Malaysia (2001) Malaysia Child Act 2001
504 Positive sexuality education approaches strive to achieve ideal experiences, rather than solely working to prevent negative experiences. They acknowledge and
address the various concerns and risks associated with sexuality, without reinforcing fear, shame or taboo of young people’s sexuality or gender inequality. For
further details, refer to with concepts expanded in Error! Reference source not found., extracted from UNFPA (2014) Operational Guidance for Comprehensive
Sexuality Education: A Focus on Human Rights and Gender
163
iii. Engage parents in the learning process, engage the progressive community and faith-based
leaders in delivering a consistent community message to increase support.
iv. Improve reach and coverage of RHSE programs addressing vulnerable communities.
v. Include the elderly within the PEKERTI’s PoA by strengthening SRH programmes and services
and RHSE for older persons.
3. Generate social support through community participation and mobilisation via mass media
campaign to: advocate for greater community acceptance of RHSE and services accounting
for religious views and cultural perspectives, engaging champions from different sectors
(public male and female figures who act as community role models); and capacity building for
the community to be empowered with the appropriate knowledge and skills.
4. Use peer-based models to transform knowledge and attitudes among children, adolescents and
young people, and introduce digital innovations to deliver the SRH messages (e.g. self-care
digital tools).
5. Establish a comprehensive M&E mechanism prior to program implementation to avoid ineffective

or duplicate efforts and ensure the efficiency of available resources.
6. Form a Task Force under the ACCRH to review the 2009-2012 PEKERTI document in terms of
overall structure; comprehensiveness and length, and consider updating the rationale, objectives,
target population and strategies; most appropriate timeframe; and ensure publication of an
official English version to facilitate international engagement.
164
APPENDIX 1:
2009-12 PEKERTI National Policy and Plan of Action
POLICY STATEMENT: The National Reproductive and Social Health Education Policy that applies to all
age demographics and aims at improving the knowledge of sexual reproductive health among Malaysian
and encouraging positive attitudes towards reproductive and social services. Reproductive and social
health education is fundamental to the development of strong and healthy human development and
mutual respect. The policy incorporates the multicultural, multiethnic and multifaith diversity in
Malaysia.
RATIONALE: The reproductive and social health education is a lifelong process for acquiring
a comprehensive knowledge of biological, socio-cultural, psychological, and spiritual aspects
towards healthy behaviours. This education and knowledge support the development of responsible
individuals.
PEKERTI OBJECTIVES:
1. To raise awareness of the community about the importance of reproductive health and social
education;
2. To develop expertise in reproductive health and social education among members of the
community;
3. To enhance research and development to improve reproductive health and social education
systems; and
4. To improve the effectiveness of implementing health and social education.
IMPLEMENTATION STRATEGY: To achieve the above objectives, strategies have been formulated
based on four (4) components, including Advocacy, Human Capital Development, Research and
Development, and Monitoring and Evaluation.
TARGET GROUPS FOR PEKERTI PROGAMME:

1. National Service Training Program (PLKN) trainees (this programme was discontinued in 2018).
2. School students (primary, secondary and special education schools).
3. Students in Institute of Higher Learning and College Student.
4. Parents and the public, in which the program is absorbed in the Family Development Program and
the Centre for Family.
165
APPENDIX 2:
Contextual Information Across Selected Muslim Countries
Table 4: Commitments to Key International Conventions/ Protocols Relevant to Reproductive
Rights and The Right to Sexuality Education
International Resolutions/ Frameworks Related

to Family Planning
Universal Declaration of Human Rights, 1948
International Convention on the Elimination of
All Forms of Racial Discrimination, 1965
International Covenant on Civil and Political
Rights, 1966
International Covenant on Economic, Social and
Cultural Rights, 1966
Alma Ata Declaration, 1978
CEDAW, 1979
Convention against Torture and Other Cruel,
Inhuman or Degrading Treatment or
Punishment, 1984
Convention on the Rights of the Child, 1989
Cairo Declaration on Human Rights in Islam,
1990
International Convention on the Protection of
the Rights of All Migrant Workers and Members
of Their Families, 1990
International Conference on Population and
Development (ICPD), 1994
Beijing Platform for Action (BPfA), 1995
Millennium Development Goals (MDGs), 2000
Convention against Transnational Organized
Crime, 2000
Protocol against the Smuggling of Migrants by
Land, Sea and Air, 2000
166
International Resolutions/ Frameworks Related
to Family Planning
Protocol to Prevent, Suppress and Punish
Trafficking in Persons, Especially Women and
Children, 2000
Convention on the Rights of Persons with
Disabilities, 2006
International Convention for the Protection of
All Persons from Enforced Disappearance, 2006
Declaration on the Rights of Indigenous
People, 2007
2012 CRC-OP-SC - Optional Protocol to the
Convention on the Rights of the Child on the
sale of children child prostitution and child
pornography
2012 CRC-OP-AC (involvement of children in
armed conflict)
Sustainable Development Goals (SDG 3 and
SDG 5), 2015
Sources: Centre for Reproductive Rights (www.reproductiverights.org); United Nations (2014). Reproductive rights are human rights: A
handbook for national human rights institutions;
https://indicators.ohchr.org/ https://www.unodc.org/unodc/en/treaties/CTOC/signatures.html;
https://www.refworld.org/docid/3ae6b3822c.html; https://www.ohchr.org/en/issues/ipeoples/pages/declaration.aspx
167
Table 5: Contextual Information Across Selected Countries (2018 Data Mostly)505
Demographics Malaysia Turkey Egypt Morocco Bangladesh

Demographics
Country Income Level⁵⁰⁶ Upper Middle Upper Middle Low Middle Low Middle Low Middle
Income Income Income Income Income
Religions Secular state: Secular state: Islam is the Islam is the Secular state,
63% Muslim 99.8% state religion state religion, but Islam is
(Sunni), Muslim post 1980, 99% Muslim the state
19% (mostly 90% Muslim (Sunni) religion.
Buddhism, Sunni), 0.2% (mostly 89% Muslim
10% Other Sunni), 9% (mostly
Christian, Coptic, Sunni), 11%
6% Hindu, 1% Other Hindu,
2% Other 1% Other
Total population (millions) 31.5 82.3 98.4 36.0 161.4

32.7 (2020)⁵⁰⁸
Total Fertility Rate (2018) ⁵⁰⁹, ⁵¹⁰ 2.0 2.1 3.3 2.4 2.0
(decreasing) (decreasing) (decreasing) (decreasing) (decreasing)
Population strategy Encourage Encourage Population Encourage Population
higher higher control higher control
fertility fertility⁵¹¹ fertility
Median age (years) 30.3 31.5 24.6 29.5 27.6
Population in millions (ages 21.9 55.1 60.0 23.7 108.3

15-64 years)
Population in millions (≥-65 9.6 7.0 5.1 2.5 8.3

years)
% Urban population 76.0 75.1 42.7 62.5 36.6
Human Development Index 0.804 (61) 0.806 (59) 0.700 (116) 0.676 (121) 0.614 (135)
(HDI) and rank out of 189
countries
Human Development Index 0.792 0.771 0.643 0.603 0.575

(HDI), female

506 World Bank (2019) Country Income Levels.
509 The World Bank (2018) Total Fertility Rate (births per woman).
510 UN Department of Social Affairs (2020) World Fertility and Family Planning 2020: Highlights
511 Yucesahin MM, Adali T, Turkyilmaz AS (2016) Population Policies in Turkey and Demographic Changes on a Social Map. Border Crossing 6:240–266
UNFPA (2016) Current overview of Turkey’s population
168
Economic indicators
Gross National Income (GNI) per 27,227 24,905 10,744 7,480 4,057
capita (2011 PPP $)
Gross Domestic Product (GDP) 28,176 25,287 11,014 7,509 3,879
per capita (2011 PPP S)
Income index 0.847 0.833 0.706 0.652 0.559
Work, employment and vulnerability
Labour force participation rate 64.6 52.5 48.1 45.4 58.7
(% ages 15 and older)
Labour force participation rate 50.9 33.5 22.8 21.4 36.0
(% ages 15 and older), female 55.2 (2018)⁵¹²
Unemployment, total (% of 3.4 10.9 11.4 9.0 4.3

labour force)
Health indicators
Health expenditure (% of GDP) 3.8 4.3 4.6 5.8 2.4
Life expectancy at birth (years) 76.0 77.4 71.8 76.5 72.3
HIV prevalence, adult (% ages 0.4 n.a. 0.1 0.1 0.1

15-49) Total 4,212
(12% )
(2018)⁵¹³
Mortality rate, infant (per 1,000 7.2⁵¹⁴ 10.0 18.8 20.0 26.9
live births)
Mortality rate < 5 years (per 8.8⁵¹⁵ 11.6 22.1 23.3 32.4
100,000 live births)
Gender indicators
Gender development index 0.972 0.924 0.878 0.833 0.895
(GDI)
Gender Inequality Index (GII) 0.274 (58) 0.305 (69) 0.450 (102) 0.492 (118) 0.536 (129)
and rank out of 162 countries
169
Gender indicators
Adolescent Fertility Rate (births 12 (2015) 26.6 53.8 31.0 82.0
per 1,000 women aged 15-19 8.5 (2018)⁵¹⁷
years) (2018)⁵¹⁶
Maternal mortality ratio (deaths 23.8 (2015) 16 33 121 176

per 100,000 live births) 23.5 (2018)
22 (2019)⁵¹⁸
Antenatal care coverage, at least 97.2 97.0 90.3 77.1 63.9

one (1) visit (%)
% of births attended by skilled 99.5 98.0 91.5 86.6 67.8

health personnel
Child marriage, women married n.a. 15 17 13 59

by age 18 (% of married women
aged 20-24)
Contraceptive prevalence, any 52.2 73.5 58.5 70.8 62.3

method (% of married or (2014)⁵¹⁹
in-union women aged 15-49)
Contraceptive prevalence, 34.3 n.a. n.a. n.a. n.a.

modern method (% of married (2014)⁵²⁰
or in-union women aged 15-49)
Unmet need for FP 19.6% 5.9 12.6 13 12.0

(% of married or in-union (2014)⁵²¹
women aged 15-49 years)
Proportion of demand satisfied 58 (2016)⁵²² n.a. n.a. n.a. n.a.

with modern methods for age
group 15-49
Violence against women ever n.a. 38.0 25.6 n.a. 54.2

experienced, intimate partner
(% of female population aged
15 and older)
516 The World Bank (2018) Adolescent fertility rate (births per 1,000 women ages 15-19)
522 ARROW (2018) National Report: Malaysia – Child Marriage: Its Relationship with Religion, Culture and Patriarchy
170
Gender indicators
SDG Indicator 5.2.1. % of 27% 34.5% 39.5% 39.4% 44.5%
ever-partnered women aged ≥
15 years experiencing physical
or sexual violence from an
intimate partner in the previous
12 months⁵²³
Violence against women ever n.a. n.a. n.a. n.a. 3.0

experienced, non-intimate
partner (% of female population
aged 15 and older)
Education indicators
Education index 0.713 0.712 0.712 0.547 0.513
Mean years of schooling (years) 10.2 7.7 7.3 5.5 6.1
Mean years of schooling, male 10.3 8.4 8.0 6.4 6.8

(years)
Mean years of schooling, female 10.0 6.9 6.7 4.6 5.3

(years)
Gross enrolment ratio, secondary 86 103 86 80 67

(% of secondary school-age
population)
Gross enrolment ratio, tertiary 42 104 34 34 18

(% of tertiary school-age
population)
Literacy rate, adult (% ages 15 93.7 96.2 71.2 69.4 72.9

and older) 96.3
(2018)⁵²⁴
% of primary schools with 100⁵²⁵ n.a. 48 79 4

access to the internet
% of secondary schools with 100⁵²⁶ n.a. 49 89 82
access to the internet
523 Global Burden of Disease Collaborative Network (2017) Global Burden of Disease Study 2016 (GBD 2016) Health-related Sustainable Development Goals (SDG)
Indicators 1990-2030. Seattle, United States: Institute for Health Metrics and Evaluation (IHME), quote in (2016) Goal 5: Gender Equality - SDG Tracker. In: Our
World in Data.
525 United Nations Development Programme (UNDP) 2020 Human Development Indicators. Based on information provided by the MoE representative within the
TWC, internet coverage might be limited in schools located in rural and remote areas.
526 United Nations Development Programme (UNDP) 2020 Human Development Indicators. Based on information provided by the MoE representative within the
TWC, internet coverage might be limited in schools located in rural and remote areas.
171
Education indicators
Population with at least some 80.8 53.1 65.3 32.2 46.7
secondary education (% ages 25
and older)
Primary school teachers trained 99 n.a. 74 100 50

to teach (%)
Primary school dropout rate (% 3.6 12.0 3.6 4.9 33.8

of primary school cohort)
Inequality indicators
Inequality in education (%) 12.1 16.5 38.1 n.a. 37.7
Inequality-adjusted education 0.627 0.594 0.376 n.a. 0.320

index
Inequality in income (%) n.a. 22.6 36.5 21.7 15.7
Inequality in life expectancy (%) 6.1 9.0 11.6 13.0 17.3

Mobility and communication indicators
Internet users, total (% of the 81.2 71.0 46.9 64.8 15.0
population)
172
APPENDIX 3:
Summary of Malaysian Studies Assessing the Existing PEERS
Curriculum
Table 6: Summary of Malaysian Studies Assessing the Existing PEERS Curriculum
Study type Study Conclusions and

Findings
Participants Recommendations
A 2012 1,695 female • Respondents had low scores for • Reproductive health knowledge
cross-sectional Malaysian knowledge of reproduction and was low and linked to religious
survey, using university pregnancy (median = 4 out of a values and cultural norms
an anonymous students and maximum score of 10), differences about sexual issues.
self- former PEERS contraceptive uses (median
administered students in 6/16) and contraceptive • Knowledge disparities were
survey527. a public availability (median 3/13), closely linked to ethnic, social,
university in particularly for those of Malay economic and parental factors.
Malaysia. Muslim ethnicity. Greater knowledge about
reproduction, pregnancy and
• Most respondents had conservative contraception was not associated
values regarding premarital sexual with more permissive values on
behaviour (median=37/40 with premarital sexual behaviours.
higher scores corresponding to
opposing premarital sex). • The main practical implication is
that reproductive health
• Multivariate analyses showed education should include
the ethnic group was the strongest appropriate teaching about
correlate of knowledge and pregnancy prevention, and how
attitude scores; Malay Muslim to use and to obtain contraception.
ethnicity significantly associated
with lower knowledge scores and
premarital sex permissiveness.
Level of premarital sex
permissiveness was inversely
correlated with reproduction and
527 Wong LP (2012) An exploration of knowledge, attitudes and behaviours of young multiethnic Muslim-majority society in Malaysia in relation to reproductive and
premarital sexual practices. BMC Public Health 12:865.
173
Findings
pregnancy knowledge score, and
contraceptive knowledge scores.
• While there was good awareness

of contraceptive types, knowledge
in how to use contraception and
where to obtain contraceptives
was limited, likely contributed
to the non-use of contraception
during first sexual intercourse or
inconsistent use among those in
a relationship.
A 2013 1,706 university • Low content recall for taught • Malaysian young people had
cross-sectional students SRHE (lowest for STIs, human received a form of sex education
survey, using (1,180 female) relationships, negotiation skills while in school, and they require
an anonymous and former and masturbation, and highest more in-depth information on
self- PEERS students for human anatomy and general this topic. Although PEERS has
administered across three biological functions). been in schools since 1989, just
survey528. (3) universities two-thirds of respondents
in the Klang • 69% recalled having had learnt recalled learning about puberty,
Valley. about sexual and reproductive sexual and reproductive system,
systems, puberty (65%) and and relationship with the opposite
(58.8%) on relationship with the sex.
opposite sex.
• Most respondents were unaware
• Significant gender differences of SRHE being taught to them
found for recalling on the topic while in class. This somewhat
of puberty; 11% more female reflects that information retention
reported this compared to their was less effective in the current
male counterparts (p<0.01). integrated curriculum.
Significant differences were also
found between ethnicities for • Although components of CSE
recalling topics. Recall for sexual were being integrated within
and reproductive system (70% the school system, a significant
for Malays; 63% for Chinese and gap remains in content and
52% for Indians) was better than delivery which should be
528 Mokhtar MM, Rosenthal DA, Hocking JS, Satar NA (2013) Bridging the Gap: Malaysian Youths and the Pedagogy of School-based Sexual Health Education.
Procedia - Social and Behavioral Sciences 85:236–245.
174
Findings
for relationship (62% for Malays; addressed via curriculum
52% for Chinese and 32% for revision, teachers training and
Indians). delivery methods to improve
information retention to
• Most respondents reported provide effective CSE.
would like more information
with regards to Biology of
reproduction (detailed
description of female and male
genitalia, explanation of bodily
developments during puberty
and menstruation) and STIs.
• More Malays wanted more

information on STIs and HIV/
AIDS relative to Indians. Chinese
wanted more on sexual desire
and pleasure and negotiating sex
with partner than Indians.
A 2018 Desk review • Barriers to CSE progress include The review calls for the
comprehensive of relevant an abstinence-based curriculum, implementation of more
review documents untrained teachers, and the lack inclusive, comprehensive,
assessing the and policies. of parental and family support, engaging and effective
implementation political willpower and a robust interventions that meet the
of CSE in M&E mechanism. needs of Malaysian unmarried
Malaysia by young people to improve
ARROW529. • More need to be done to address sexuality education and link
STIs, unwanted teenage pregnancies, it with available SRH services
sexual violence and child sexual staffed with trained health
grooming to achieve progress professionals to better inform
towards the SDGs, particularly the young people, particularly
quality education and gender the marginalised ones in the
equality, and the ICPD PoA priority spirit of leaving no one (1)
actions. behind.
175
Findings
In-depth • Key informants agreed that the • A multi-sectoral approach to
interviews implementation of sex ensure the effective
with key education has progressed far implementation of CSE for
informants since its introduction in 1989. in-and out-of-school adolescents.
from MoE, PEERS is perceived as well-
MoH, NPFDB received, comprehensive and • Abstinence-only education is
and NUTP. relevant. Teachers still feel not sufficient to address the
uncomfortable to teach subjects SRHR needs of young people.
related to SE because they feel
• Existing programmes may not
like they have not received
reach all young demographics,
sufficient training.
disadvantaging those in rural
areas and those out of the
• Informants agreed that the
school system.
PEERS curriculum and all other
NPFDB and MoH programmes • All respective ministries/
are abstinence-only programmes agencies interviewed were
believed to be suitable to the contributing towards the
Malaysian culture. NPFDB stated implementation of SRHE in
that their programmes in schools Malaysia via several modules
are carried out with the general providing RHSE to young people
assumption that all the students and other groups of the population.
are not sexually active. SE is NPFDB used modules Modul
centred towards adolescents Cakna Diri (adolescents and
with high-risk sexual behaviour. parents edition) and SRH Module
for Boys (16-24) in their RHSE
• A key informant noted that there programmes. Modules such as
is nothing comprehensive about Adolescent Secret and
the SE implemented in Malaysia; Adolescent Searching for Love
both in terms of reach and content. developed by MoE were used in
MoH’s SRHE programmes. MoH
also reaches young people via
their PROSTAR school programme.
• However, participants
acknowledged a need for one
(1) agency to consolidate the
efforts made by various
agencies and champion the
cause on CSE implementation
in Malaysia.
176
Findings
14 Focus Group • FGDs with adolescents noted • The current curriculum is
Discussions limited understanding of CSE abstinence and fear-based and
(FGDs) with (misconceptions) and PEERS, focuses on the reproductive
104 adolescents poor recall of topic coverage, system. A comprehensive revision
aged 15-19 receiving abstinence-only sex of the PEERS curriculum should
years from education, sex as a taboo topic take place, incorporating key
school, juvenile for girls; limited understanding elements of gender, sexual
rehabilitation of gender as a biological attribute; rights, pleasure, diversity and
centres and a ignorance towards adolescent HIV prevention.
halfway home RHR needs; misconception about
for pregnant accessibility to SRH services and • Involve students, teachers and
girls (64% fear of discrimination; contraception parents in the development of
females). knowledge alone is not sufficient the curriculum.
to prevent unprotected sex; the
need for information on STIs and • Varying teaching methods and
early signs of pregnancy; use of the integration of SRHE topics
electronic platforms to access into various subjects may
pornography; contradicting roles impact the low recall of topic
played by parents: educator vs coverage.
moral police.
FGDs with 29 • FGDs noted that PEERS is viewed • Experts should be included
parents and as SE, but there is a limited in the school system for more
teachers. understanding of CSE. Sex is a accurate, precise and complete
taboo topic and highly sensitive, SRHE information.
and SRHE should be culturally
and religiously sensitive; • Use innovative digital technologies
abstinence only is considered to reach young people.
most appropriate to be taught
in schools and the current • Improve training and support for
curriculum highlights the teachers.
negative outcomes of sex to
instil fear of STIs, pregnancy • Engage parents in the teaching
and abortion; teachers claimed process.
that only 10%-20% of the entire
syllabus is allocated to SRHE in
a year; 70% of adolescent learn
about sexuality from social
media and 30% from school;
teachers fear being misinterpreted
177
Findings
and experience a lack of
resources and lack of PEERS
training, which makes them
uncomfortable teaching SRHE;
all participants agreed that RHSE
subject experts should be
included in the school system
for more accurate precise and
complete RHSE information;
gender is seen as biologically
determined and that the
curriculum should incorporate
a broader coverage of gender,
including non-conforming
gender roles to identify students
needing special counselling,
religious bodies or special
health facilities for rehabilitation
and transformation. Parents
were concerned about children’s
development, and noted schools/
teachers can improve SRH
knowledge and skills. Teachers
noted that parents should be
more involved.
178
APPENDIX 4:
Summary of Recommendations Based on The Evidence
for TWC’s Consideration
Gaps and Expected Propose Lead
Recommendations Rationale Indicators
Barriers Outcomes Agency
1. Establish comprehensive collaboration and policies
Limited Revive the ACCRH, to Coordination ACCRH in ACCRH to MWFCD
coordination improve the quality and collaboration working order develop clear
and collaboration of reproductive and across key agencies with supporting guidelines on NPFDB;
across key sexual health are critical to documentation the provision
agencies education by advance and including of sexuality MoH;
• Most adolescent strengthening the sustain SRH membership education and
policies either ACCRH role: programs, and specific services. MoE;
overlook the i. Oversee the planning, share expertise, roles and
RHSE and implementation experiences and responsibilities, Full NGOs
services needs and M&E of the lessons learn in clear decision- implementation Representatives
of adolescents, 2020-24 PEKERTI’s implementing making processes, of rights-based, from young
with the PoA to address key SRH programmes and a convening informed choice people,
exception of priorities; and services, schedule and of CSE for teachers,
the 2006-20 avoid duplication secretariat led young people. parents,
National ii. Integrate RHSE and inefficiency by NPFDB. religious and
Adolescent and service delivery and support Policy reforms community
Health Plan of (e.g. consider creativity and ACCRH to develop likely to improve leaders; and
Action, which FRHAM’s expertise innovation. an M&E plan the lives of
identified SRH in rolling out for the PoA Malaysian health
as a priority teachers’ training) Rationale for prior to its young people profession
area and mainly and increase membership: implementation. (e.g. the also from
know to MoH’s multi-sectoral young people’s minimum age different
clinics and collaboration and other voices of marriage ethnic groups.
hospitals. and coordination should be given in Malaysia
across key stake- a platform to should align with
• The 2009-12 holders (involving incorporate international
PEKERTI’s PoA governmental, their concerns standards and
did not specify NGO and private and suggestions be set to 18 years
the extent to partnerships, regarding for all legal
which RHSE referred to as 3Ps sexuality frameworks,
and services for public, private education and including
would be made and partnerships); services to civil, Muslim
available to address their and native
the unmarried iii. Oversee and needs, understand customary
young people. validate the the causes being laws without
adaptation of CSE championed and exceptions).
curriculum to the implications
of these reforms
179
1. Establish comprehensive collaboration and policies
Malaysia’s multiracial and increase
and multifaith commitment at
context based on the grass-root
human rights; level (schools,
teachers, service
iv. Specify the extent providers and
to which CSE and programme
services would be personnel).
made available
to the unmarried
young people
(ensure inclusivity);
and
v. Advocate to
strengthen CSE
related laws,
policies and
frameworks for
young Malaysians.
ACCRH membership
to include at least
one (1) champion
from young people,
teachers, parents,
religious and
community leaders
and health
professionals from
different ethnic
groups (to ensure
inclusivity) as well as
Government
agencies and NGOs.
Train ACCRH
members in gender
mainstreaming of
programmes and
monitoring of gender
indicators.
180
2. Improve the RHSE curriculum and programmes and their delivery
The PEERS Improve and align Despite the A rights-based, A CSE curriculum MoE and
curriculum the content of RHSE PEERS curriculum, and gender- that is culturally
promotes with international the 2014 MPFS focused appropriate. MoHE.
abstinence-only best practices. and other curriculum
based • Adapt international Malaysian studies delivered as Number of
misconceptions guidelines to revealed that a stand-alone schools
that CSE Malaysia’s multiracial SRH knowledge subject or as implementing
encourages and multifaith among adolescents part of other CSE at national,
promiscuity society by is very limited. subjects state and
• Content limit- incorporating four incorporating district levels.
ed to sexuality (4) CSE components: Barriers in further key elements:
and reproductive rights, participation reductions in gender, SRH
health, excludes and agency; SRH AFR include limited and HIV, sexual
safer sex and and behaviours; SRHE and rights and sexual
contraception, gender equality contraceptive citizenship,
instils fear of and power; and practice, indicating pleasure, violence,
sexuality and positive sexualities the urgent need diversity and
STIs, pregnancy and respectful to incorporate relationships.
and abortion. relations. a women
empowerment Up-scale RHSE
component. programmes
• Does not align • Include right-based
with UNESCO’s and gender-focused • Develop policy
curriculum principles both Strengthening guidelines
guidelines. in school and young people’s and detailed
community psychosocial to PoA that is
• Lacks the CSE programmes to protect them explicitly
rights-based empower young from risky sexual linked to
and gender- people in making behaviours. education
focused informed decisions Consider adding: sector plans,
principles. about sex and as well as to
i. Comprehensive
sexual other national
reproduction
• Lack of parents’ behaviours530. strategic plans
and pubertal
acceptance and and policy
changes;
engagement. • Refer to WHO’s frameworks
Core Global on young
ii. Appropriate
• Public health Indicator Framework people SRH.
explanation
concerns when developing
of sexual
related to the curriculum content • Circulate it to
intercourse,
consequences and for its M&E, the schools;
safe sex and
of premarital highly relevant for support
the use of
and unprotected addressing implementation
contraception
unintended of RHSE
aligned with
pregnancy531. programs;
530 UNFPA (2014) UNFPA Operational Guidance for Comprehensive Sexuality Education: A Focus on Human Rights and Gender
181
sex which • Content should be local norms, address
disproportionately developmentally values and sensitivities
affect girls and age-appropriate culture (how concerning the
(STIs and and more visual to use and implementation
HIV/ AIDS, with illustrations, where to get of RHSE
unintended making the lessons contraceptives, programs;
teenage more effective (as a complete and protect
pregnancy, in Bangladesh). definition of and support
unsafe abortion abstinence); teachers
and baby • Engage and collaborate responsible
abandonment). with young people, iii. Empowerment for delivery of
parents and teachers and gender RHSE.
• In 2018, in developing equality,
there was a the curriculum to covering
reduction in ensure its consequences
the number relevance. of unequal
of schools power dynamics
participating • Health experts and toxic
in the PEKERTI should be included masculinities
@ Schools in the school and how
program due system for more to address
to budget accurate, precise them), healthy
constraints. and complete relationships
SRHE information. and negotiating
non-violent
• MoE to ensure solutions,
district-level personal safety
teachers receive measures,
RHSE training to consent, SRH
delivery of the rights and
curriculum. sexual diversity.
Poor Improve and align The effectiveness Establish Assessment MoE and
implementation the delivery of RHSE of the teachers an M&E of students’
of RHSE with international depended on mechanism to knowledge MoHE.
curriculum in best practice. the strategy assess both attitudes,
schools • Improve teachers and method of student beliefs and
• Significant gap training, delivery teaching knowledge behaviours pre
in content and methods (use used by the and teachers’ and post-
delivery. a participatory teachers. performance. delivery.
teaching approach)
• Shortage and ongoing support. The delivery Develop Assessment
of teachers mode is extremely implementation of teachers’
trained in important to plans such as knowledge,
RHSE and increase the how to select attitudes,
services. schools’ and train beliefs and
182
• Teachers felt • Use a participatory commitment, teachers who behaviours
uncomfortable teaching approach develop the are responsible in pre and
delivering the that encourages teachers’ skills for teaching the post-delivery
curriculum dialogue, conveys and build their subject, lesson and assessment
due to positive views comfort and plans, number of the training
shortcomings of sexuality and confidence in of hours, how modules and
in their own does not rely on delivering the subject is to school’s
training, support, shame/ fear-based sexuality be incorporated commitment
school strategies. education. it into the current and support.
leadership and timetable,
commitment, • Capacitate teachers A participatory the mode of Assessment
so they either and parents with teaching delivery, provision of parents’
avoid it or accessible sexuality approach allowing of resources knowledge
address it education module. the students to (including attitudes,
ineffectively. ask questions materials). beliefs and
• Improve has been proven behaviours pre
• Delivered in connectedness successful in Create a team and post-
unclear and between parents increasing to develop and delivery and
fragmented and school by students’ recall implement assessment
across engaging parents and influencing RHSE specific of support to
subjects, not with school-based networks. indicators at students.
examined, sexuality program. national and
which leads to state levels. Suggested
teachers • Consider involving indicators for
either avoiding the NGOs (FRHAM) Create a young outcomes532:
or addressing in the training of people team
it ineffectively school teachers. to ensure their % of young
(teachers use meaningful people who
of metaphors • Consider involving participation in participate in
causes trained young M&E activities RHSE;
confusion). doctors and school at national,
health nurses state and district %of RHSE
• Leads to poor (more acceptable levels. participants
student recall information sources) who demonstrate
of reproduction in delivering SRH critical thinking;
and pregnancy, seminars to link Reported
contraceptive sexuality education changes in
uses and and services. knowledge
contraceptive about: safer sex
availability, • Consider integrating and transmission
particularly the curriculum into of HIV; accessing
Malay Muslim one (1) compulsory and using
females, and examinable contraception
increasing subject for teachers and human
and students to rights;
532 Extracted from UNFPA (2014) Operational Guidance for Comprehensive Sexuality Education: A Focus on Human Rights and Gender
183
their take the subject Reported
vulnerability seriously. changes in
to abuses, STIs attitudes on
and unintended • Strengthen the gender norms;
pregnancy. monitoring girls’ sense of
mechanism within agency and
• Lack of parental the education greater intent
support and system, from the to delay
engagement. national level pregnancy;
Training of Trainers boys’ beliefs
• Students to curriculum regarding
would rather teaching in traditional
SRH be taught schools. gender roles
by teachers and stereotypes;
than by parents. respect for
human rights,
• Lack of including
systematic the rights of
evaluation people
in terms of living with HIV;
quality and tolerance of
effectiveness. sexual diversity;
the sense of
• MoE believes connectedness
that RHSE to school;
would be best perception of
practised once power balance
it considers in intimate
the context, heterosexual
religion and relationships;
culture of
pupils. Reported
changes in
behaviour:
delay in sexual
initiation;
increase the
use of the
male or female
condom,
contraception;
decrease in
experience or
perpetration
of sexual
coercion and
intimate partner
184
violence; girls’
participation
in social/ safe
spaces
programmes;
boys’ participation
in exercises
that help them
to reflect
on norms/
expectations
and self-
perception;
positive
interactions
with mentors.
Lack of parental Engage parents in Parents/ guardians/ Increase parent Development MWFCD and
engagement the teaching and caretakers must and family of programmes/ NPFDB.
learning processes understand the engagement in information
to get their support RHSE lesson plan providing RHSE bank.
to ensure that the to be delivered to young people.
information being to adolescents, Number of
taught at schools can participate in Encourage schools carrying
be reinforced in the their homework a healthy out the
family home. and assignments parent-child programmes.
and be encouraged relationship and
to speak to their communication.
children about
RHSE. Increase
school-parent
connectedness.
The needs of Consider governmental FRHAM is the only A government A funding NPFDB and
out-of-school financial support for NGO providing budget line to budget across FRHAM.
vulnerable NPFDB and FRHAM to SRH and FP support NGOs in the duration
youth are scale-up the delivery services either delivering out- of the strategy
generally poorly of the out-of-school free or cheaply of-school youth (2020-24) to
meet. RHSE programme. via its Youth programmes. support out-
Health Services of-school RHSE
• Limited
Ensure that at the state level Increase coverage programmes.
coverage of
programmes reach with funding of rural areas
youth-friendly
the ground level from international and vulnerable
sexuality
(such as districts and donors. young people
education and
rural schools). (particularly
services via
those with non-
Youth Health
185
Services by Focus on investing in Several out-of- conforming
FRHAM targeted programmes that are school RHSE sexual orientation)
to married far-reaching and will programmes in the spirit of
and unmarried improve the lives of are delivered leaving no one
vulnerable young people. by NPFDB and (1) behind.
young people FRHAM via IEC
due to limited Analyses of national materials and
human and indicators and adolescent SRH
financial documentation of training mod-
resources and adolescent SRH ules (including
funded by needs should inform FP and HIV).
donors such future investments
as UNFPA. on geographical
areas and regions
• Uneven with greatest SRH
geographic needs.
coverage of
adolescent SRH Lessons from
programmes implementing CSE
concentrated in Bangladesh
in urban areas. and Egypt: Engage
trained peers.
• No specific
programme
meets the
SRH needs of
young people
marginalised
for their non-
conforming
sexual
orientation
except for PT
Foundation and
Safe Clinic,
providing
HIV-related
information
in the Klang
Valley.
• Gender
diverse
adolescents
avoid using
SRH services
due to fear of
186
identity
exposure,
increasing
the risk for
physical and
mental health
issues such as
contracting STI
and HIV.
3. Run a mass media campaign to advocate for greater community acceptance of RHSE and services
Lack of media Generate greater Most adults are Develop a Improvement NPFDB
advocacy and public awareness, reluctant to give structured in community
a community desensitise the issue adolescents communication knowledge,
communication and generate open accurate sexual plan with attitudes,
plan. discussion on RHSE information for messages that believes and
• Barriers to and services. fear of promoting engage men & behaviours
addressing early sexual boys, girls & (measured
young people’s A more pro-active activity, but women. via pre and
SRH needs stand from the accurate CSE post-campaign
included government to will empower Resources and surveys).
strong religious engage the media in young people, outcomes of
sensitivity and conveying the need reduce unwanted evidence-based
socio-cultural for and the positive pregnancies, research,
taboo attached impact of RHSE for unsafe abortions, programmes
to sexuality, young people’s STIs and enable and services
with a very health and well- their health and should be widely
narrow learning being. well-being. disseminated
scope from via mass media.
parents, Prioritise awareness- Creating an
guardians, raising of the benefits enabling A multidisciplinary
elders and of FP for families environment effort is required
peers due to and communities prior to from the
conservativeness linked to FP services implementing government,
rooted in the referrals. RHSE is critical, policymakers,
culture. including educationists,
Consider referring involving local health
to the SBCC: Guide religious leaders. professionals,
to Designing SRH Addressing experts in religion,
Programs for Youth young people’s social activists,
in Egypt533 when SRH requires NGOs. Urgent
designing an SBCC multi-sectoral need to train
plan for Malaysia. interventions implementers
533 Johns Hopkins Center for Communication Programs (2017) Social and Behavior Change Communication: Guide to Designing Sexual and Reproductive Health
Programs for Youth in Egypt
187
3. Run a mass media campaign to advocate for greater community acceptance of RHSE and services
Produce fact-based, that involve (e.g., teachers
age-appropriate government and social workers)
educational resources, agencies, civil and parents to
including textbooks, society, religious enhance the
handouts and videos institutions, effectiveness of
and websites. mass media, as RHSE programs.
well as parents.
4. Improve SRH service awareness, delivery and accessibility

Poor uptake of Improve universal, It is critical that Uptake of Increased MoH
available SHR equitable access SRH services adoles- uptake of
information and use of quality FP and education cent-friendly Youth Health
and services services by focusing are integrated. health centres Services.
due to lack of on vulnerable will likely
awareness or populations. SRH services improve as a
discrimination to focus on result of awareness
from health Support data collection availability, raining and
care providers. for FP resource accessibility, quality transforming
allocations. and accountability, beliefs and
• Barriers exist
including universal behaviours.
due to
SRH (contraception) access to rights,
conservative
information and accounting for Initiatives
community
services should be diverse contexts addressing
views, which
made available to that affect some of these
limit the
adolescents regardless women access challenges
provision of
of their marital that compromise started being
SRH services
status. their right. implemented:
(including
contraceptives
Improve the Focus on vulnerable Malaysia started
or STIs services)
integration of SRH populations universal access
to married
services within the (young people, to SRH services
adolescents.
PHC system. women/ girls for all adolescents
vulnerable to in primary,
• Adolescents
Develop a referral unwanted secondary and
considered
system to ensure pregnancies, tertiary healthcare
SRH services
young people are Orang Asli, facilities
and providers
referred to migrant workers, nationwide in
disrespectful,
appropriate SRH disadvantaged 2012. MoH led
lacking privacy
services, care and rural areas, the provision of
& confidentiality,
support. people with SRH services for
& judgmental.
HIV/ AIDS, GBV both married
Review the 2009 survivors). and unmarried
• Non-clinical
services are MoH training sessions adolescents,
more likely on adolescent SRH by issuing the
to be utilised and counselling for 2012 Guidelines
on Managing
188
• by unmarried health professionals Raising young Adolescents
adolescents to deliver services people’s SRH Issues in
than clinical in a professional, awareness of Health Clinics
services. non-judgmental FP benefits for to support
manner and address themselves, Youth Health
• RHSE young people’s their families and Services, but
programmes needs, including communities as the uptake is
are not linked abortion laws and a priority poor.
to services. exceptions. targeting both
boys and girls.
• It is generally Collection and report
assumed that service access and
the government legal abortion
does not statistics for proper
provide allocation of resources.
contraceptive Review policy and
services to laws that require
unmarried parental consent
young people. for accessing the
services to ensure
• However, that SRH services are
married and available to
unmarried adolescents safely
pregnant and confidentiality.
women access
perinatal Consider replacing
services at the vertical, one-
health facilities. size-fits-all FP
service delivery
• Healthcare model to differential
facilities may approaches to
not be able address the needs of
to provide specific population
accurate and groups (regional
complete service packages
information to including behaviour
women who communication
may seek change and service
abortion services. delivery components,
focusing on low-
performing regions
and pockets of
hard-to-reach where
service coverage is
low and the
disadvantaged
urban. Evaluate
189
ongoing programs
and scape-up
effective ones.
Delivery of Youth Improve Government FRHAM

Friendly Services publicity of clinics to work
(YFS) to provide SRH, clinics in the closely with
including FP services community, NGOs and
which young people particularly youth peer
trust and feel is increase educators in
there for them and acceptance promoting their
their needs. among parents. services.
Assess the existing NGOs can refer

services to identify their young
and address barriers. clients for the
services, and
Develop National youth peer
Operational educators can
Guideline for YFS for spread the
service providers to news about the
ensure quality and availability of
be used as an M&E the services
tool. among their
peers.
Improve the delivery
of youth-friendly
services according
to IPPF’s guidelines:
• Train providers to
deliver SRH services
in a sensitive and
respectfully
manner;
• Maintain privacy
and confidentiality;
• Convenient clinic
opening hours
for young people
(evenings and
weekends);
190
• Accessible to all
young people
regardless of age,
marital status,
ethnicity, religion,
sexual orientation
or ability to pay;
• Establish an
effective referral
system;
• Involve young
people in designing,
implementing and
evaluating the
program; and
• Engage key
stakeholders in the
local community,
such as partners,
parents/ guardians
and schools.
5. Establish comprehensive monitoring and evaluation mechanisms

Limited National data on Regular A mapping NPFDB.
comprehensive, young people’s comprehensive of RHSE and
integrated and sexuality and data is required service data
up to date SRH reproductive health to inform policy, collected across
data to inform and FP needs. programs, and surveys and
planning • More regular research. related reporting
National data surveys capturing timelines to
sources with comprehensive Surveys tend to inform the
large time gaps. SRH information capture the FP integration of
• The National (refer to the SYPE methods of regular data
Study on SRH survey in Egypt) married women collection to
only (overestimating inform RHSE
of Adolescents on married and
CPR and and services
is conducted unmarried young
underestimating planning.
by NPFDB people to measure
unmet needs) to
every decade trends and change
prevent unwanted
and collects in knowledge,
adolescent
limited data. attitudes, sexual
pregnancies,
practices.
consider
capturing
191
• The MPFS • Conduct quality, comprehensive
captures limited in-depth studies FP data regardless
SRH data among to improve of marital status.
Malaysian interventions. All
young people. research to be
coordinated to
• Small scale avoid duplication.
studies vary Share research
in geography, findings via regular
coverage, conference or
focus, and publications.
age range:
National • Consider collecting
Surveys from strong indicators
the Department regularly
of Statistics, disaggregated by
Malaysia; age, sex, economic
Global School- status and location
based Student (via census and
Health Survey other surveys
Malaysia on attitudes and
2012’s fact behaviours in
sheet; 2015 targeted districts)
Malaysian Youth for effective
Sexual and planning, budgeting
Reproductive and monitoring
Health Survey. of National Social
Policy (NSP)
implementation at
the local level and
better targeting
of disadvantaged
groups.
Limited use Use innovative There is a strong Number of NPFDB and

of innovative, digital technologies reliance on innovative FRHAM.
non-traditional to reach young traditional initiatives
and age- people such as the approaches such piloted.
appropriate use of Information as peer-education
interventions in and Communication or community-
adolescent SRH Technology (ICT), based awareness-
programming. game-based or raising programs
interactive (important entry
interventions. points for those
aged 10-14).
192
Consider non- Innovative
traditional approaches, approaches and
such as sports-based technologies are
interventions, underutilised.
psychosocial
counselling, mental
health counselling.
Consider a distinct
programmatic area
with strong technical
interface with other
areas to attract
and reach greater
numbers of young
people, with SRH
and gender equality
information and
services.
Consider promoting
the website the
Malaysian Care for
Adolescent Project
(MyCAP), created by
health professionals
for online RHSE
among Malaysian
young people.
Lack of an Establish a robust A strong M&E A stronger CSE Number of MoH;

overall M&E mechanism to framework M&E mechanism. training (per NPFDB and
robust M&E measure progress, can identify year) completed FRHAM.
mechanism validate, replicate interventions A team at National,
• Limited rigorous or scale up best that improve overseeing State and
evaluation and practices in Malaysia. adolescent’s indicators at the District level.
documentation • Implement more SRH knowledge, national, state • Number of
of what works. methodologically access and and district young
rigorous quantitative uptake of services level. people’s
• Most programmes and qualitative as well as gaps participating
did not conduct evaluation studies programming Team at national at each
rigorous impact using longitudinal knowledge state and monitoring
evaluations designs to inform and practice district levels level.
necessary to the factors to build an
inform evidence- contributing to evidence-based
based SRH program effectiveness. scale-up of
programming. promising
193
• Mainstream gender interventions, Schools/
in all outcome areas limit ineffective teachers:
for gender equity or duplicate • Number of
and women’s efforts and teaching
empowerment. ensure the hours and
efficiency of topics
• Consider a available completed.
population-related resources.
observatory to • Number of
M&E Strategies’ students
implementation reached.
that collects
and harmonises
available data and
indicators; and
assess/ bridge data
gaps with new
surveys or
innovative research
methods such as
crowdsourcing
and big data
methodologies.
• Establish databases
containing
effective programs
and measures for
dissemination of
informed practice.
• Monitor program
implementation
and service
provision for
young people by
key agencies,
focusing on progress
made, facilitating
factors, gaps and
constraints, and
emerging issues.
• Conduct regular
client’s exit
interviews and
assessments on
194
the capacity of
service providers
to assess the
effectiveness and
efficacy of the
programmes and
services. Integrate
the M&E framework
across key agencies
for more reliable
and useful
information.
195
196

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UNITED NATIONS POPULATION FUND, MALAYSIA

SITUATIONAL ANALYSIS ON FAMILY PLANNING AND

National Library of Malaysia

No. Tel: +603-2613 7555

TUAN HAJI ABDUL SHUKUR ABDULLAH

In Malaysia, Family Planning, since it was introduced in

• National Population and Family Development Board (NPFDB)

9. CONCEPTUALISING FAMILY PLANNING 21

ACCRH Advisory and Coordinating Committee for Reproductive Health

NIPORT National Institute of Population Research and Training

10. Table 10: 104

11. Table 11: 107

Several international frameworks, including the International Conference on Population and

Rational utilisation of existing limited national resources is a significant challenge to improving

2. Specific Lessons For Malaysia

Malaysia acknowledges the importance of FP policies and programmes on fertility regulation as

²⁰ NPFDB (2010) Second Malaysian Population Strategic Plan Study 2010

Malaysia’s Family Planning Context

1. FP services are conducted through a multi-sectoral approach between implementing agencies,

21 Dr Ariffin M and Love T (1968) The Family Planning Program

The Need to Develop a Family Planning Policy for Malaysia

International Family Planning Commitments

The review aimed to achieve the following objectives:

Selection of Comparative Muslim Countries

1. Document review, including the following activities:

iii. Review of national policies and guidelines of the selected countries.

Guiding Frameworks for Developing a Family Planning Policy

30 FP2020 (2014) Family Planning Effort Index

Processes Key indicators / Considerations / Intervention areas

Background information Key data; indicators to be included:

36 UNFPA Choices not Chance, UNFPA Family Planning Strategy 2012-2020

Identify targets, indicators and

3. The Family Planning Policy Development Process

i. Characteristics of high impact Family Planning policies and programmes

Study type Findings

Family Planning Policies

Family Planning Programmes

2008 survey of key elements of • The 10 elements of FP programme success include:

Family Planning Programmes

Family Planning Programmes

iii. Incorporates monitoring and evaluation (M&E) activities as

iii. Financing Family Planning policy and programmes

v. Monitoring and Evaluating Family Planning policies and programmes

The Islamic Perspective of Family Planning

Modern contraceptives, the restructuring of FP programmes and the international agreements on

44 Family Planning 2020 Track20 website

Table 3: Religious context across selected countries50

Country Religious context

Bangladesh Husbands' disapproval of FP is still a deterrent to women's regulation of fertility. This

2. Women’s Need for Family Planning

Family Planning Policies and Services Across The Islamic World

Contextual Situation Across Selected Countries

1. Demographic Trends and Human Development Indicators

Population Pyramids (%)

Population Pyramids (%)

Population Pyramids (%)

Population Pyramids (%)

i. Maternal and child health

ii. Family planning

The prevalence of premarital sex is used as a proxy to measure shifts in adolescents’

iii. Adolescent fertility rate and related issues

Limited SRH education, including contraceptive practices, are well-known barriers to

iv. Sexuality transmissive infections, including HIV/ AIDS

Family Planning Policy Environment Across Selected Countries