Reproductive Health Policy in Tunisia

Although Tunisia is regarded as a pioneer in the Middle East and North Africa in terms of women’s status and rights, including sexual and reproductive health and rights, evidence points to a number of persisting challenges. This article uses the Health Rights of Women Assessment Instrument (HeRWAI) to analyze Tunisia’s reproductive health policy between 1994 and 2014. It explores the extent to which reproductive rights have been incorporated into the country’s reproductive health policy, the gaps in the implementation of this policy, and the influence of this policy on gender empowerment. Our results reveal that progress has been slow in terms of incorporating reproductive rights into the national reproductive health policy. Furthermore, the implementation of this policy has fallen short, as demonstrated by regional inequities in the accessibility and availability of reproductive health services, the low quality of maternal health care services, and discriminatory practices. Finally, the government’s lack of meaningful engagement in advancing gender empowerment stands in the way as the main challenge to gender equality in Tunisia. Nada Amroussia, is a master’s student at the Department of Epidemiology and Public Health Sciences, Umea University, Sweden. Isabel Goicolea, MD, PhD, is Associate Professor at the Department of Epidemiology and Public Health Sciences, Umea University, Sweden. Alison Hernandez, MPH, PhD, is a researcher at the Department of Epidemiology and Public Health Sciences, Umea University, Sweden. Please address correspondence to the authors c/o Nada Amroussia, Department of Epidemiology and Public Health, Umea University S-901, 85 Umea, Sweden. Email: [email protected]. Competing interests: None declared. Copyright © 2016 Amroussia, Goicolea, and Hernandez. This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original author and source are credited. Health and Human Rights Journal HHr HHR_final_logo_alone.indd 1 10/19/15 10:53 AM n. amroussia, i. goicolea, and a. hernandez / papers, 183-194 184 D E C E M B E R 2 0 1 6 V O L U M E 1 8 N U M B E R 2 Health and Human Rights Journal Introduction Tunisia is regarded as a pioneer in the Middle East and North Africa in terms of women’s status and rights.1 In 1956, it was the first country in the region to abolish polygamy and, in 1973, was the first to legalize abortion. Moreover, it is the only country in the region that has withdrawn all its reservations to the Convention of Elimination of All Forms of Discriminations against Women (CEDAW). Since 1966, Tunisia has also run a successful family planning program. As part of this program, the National Board for Family and Population was created in 1973. In 1994, the United Nations Population Fund (UNFPA) designated Tunisia as a Centre for Excellence in terms of its population activities.2 The 1994 International Conference on Population and Development (ICPD) marked an important transition in Tunisia’s population policy, as it led the country to abandon its focus on purely demographic concerns and instead embrace reproductive health as a priority per se in national health programs.3 In fact, despite the importance of the Millennium Development Goals and the Sustainable Development Goals in putting issues such as maternal health, gender equality, and women’s empowerment on the international agenda, the ICPD Programme of Action is still regarded as the most comprehensive international document on sexual and reproductive rights.4 Since 1994, women’s reproductive health indicators in Tunisia have shown improvements. By 2012, the unmet need for contraception was just 7%.5 Skilled attendance at delivery increased from 76.3% in 1990 to 97.6% in 2013, and the maternal mortality ratio declined from 91 per 100,000 live births in 1990 to 46 per 100,000 in 2013.6 However, it has not all been progress. According to a 2010 shadow report submitted to the CEDAW Committee by Tunisia’s Democratic Women’s Association, women in Tunisia are subjected to numerous violations of their sexual and reproductive rights, including discrimination against unmarried women, virginity testing, and the criminalization of homosexuality.7 Over the last five years, Tunisia has undergone a political transition characterized by new aspirations for democracy and respect for human rights. Throughout this period, women’s rights, including their sexual and reproductive rights, have been one of the most debated topics in the new republic. As a contribution to the post-democratic transition debates concerning women’s rights, this article presents a gender-sensitive human rights-based analysis of Tunisia’s reproductive health policy between 1994 and 2014. Theoretical framework After a long history of marginalization, reproductive rights were globally recognized in the ICPD. Although these rights are still controversial and contested in many settings, they do not represent a new set of rights. Indeed, they reflect the very rights that have been long established in human rights treaties—for example, the right to life, the right to physical integrity and the right to health. As fundamental human rights, reproductive rights are universal, inalienable, indivisible, and interrelated; they apply to all human beings equally without discrimination, and they require application of the principles of participation, inclusion, accountability, and the rule of law. Hence, states are obligated to respect, protect, and fulfill these rights, and citizens can hold the state accountable for this obligation.8 This constitutes the basis for a human rights-based approach. Women’s right to reproductive health entails the government’s responsibility in providing available, accessible, acceptable, and high-quality reproductive health care services, as well as ensuring that women can make free decisions regarding their sexuality and reproduction.9 According to General Comment No. 12 of the United Nations Committee on Economic, Social and Cultural Rights, availability refers to the adequate supply of reproductive health facilities, goods, and services. Accessibility requires that these services be non-discriminatory, physically accessible, affordable, and accessible in terms of their information. Acceptability means that these services and goods must be culturally and ethically acceptable, while quality means that they must be medically and scin. amroussia, i. goicolea, and a. hernandez / papers, 183-194 D E C E M B E R 2 0 1 6 V O L U M E 1 8 N U M B E R 2 Health and Human Rights Journal 185 entifically appropriate.10 Women’s reproductive health and rights are affected by the social organization of gender relations. Gender inequality is responsible for women’s vulnerable status and limits their abilities to make free decisions about their bodies and their lives.11 It also leads to harmful practices, such as gender-based violence, which can affect women’s health. Gender empowerment and women’s rights, including reproductive rights, are inextricably linked.12 For example, the right to have control over and to make free decisions about reproduction and reproductive health requires empowerment; women cannot enjoy this right if they are economically dependent or politically excluded.13 Education is also crucial for improving women’s knowledge about the availability of reproductive health services and for ensuring their access to these services.14 Moreover, gender empowerment improves women’s economic and social status, thus creating a positive environment in which they can claim their rights.15 Examining the state of gender equality is therefore critical to understanding the environment that shapes women’s capacity to exercise their rights. In this light, we used the Health Rights of Women Assessment Instrument (HeRWAI) to analyze Tunisia’s reproductive health policy. Our aim was threefold: (1) to explore the extent to which reproductive rights have been incorporated into the country’s reproductive health policy; (2) to determine gaps in the implementation of this policy; and (3) to examine how the gender empowerment process has been influenced by this policy.