International Forum on Population and Development

Keynote Address by Thoraya Ahmed Obaid, Executive Director, UNFPA

I am honoured to have the opportunity to speak about an issue, which lies at the heart of the Cairo agenda, and that is reproductive health.

In the specialized sessions of this Forum, we are focusing on reproductive health and family planning, HIV/AIDS and maternal death, for example. Therefore, my statement aims to remind us all of what has been agreed upon in Cairo on reproductive health and family planning so that the case studies that will be presented can be examined within the context of the 1994 International Conference on Population and Development (ICPD) itself.

The Road to Cairo

To more fully appreciate the significance of the ICPD focus on reproductive health, it is worth looking back. As you will recall, the long road to Cairo was dominated by the demographic imperative to deal with population growth. Population policies and programmes were developed, family planning services became widely available and a new generation of family planning methods expanded contraceptive choices.

During the course of only three decades preceding the Cairo Conference, the total fertility rate dropped in developing countries as a whole from 6.1 to 3.9 births per woman. And contraceptive prevalence skyrocketed from 9 to 51 per cent. It is no exaggeration to state that this constituted a reproductive revolution. New technologies took contraception outside secrecy and closets, and effective and reversible contraceptive methods were developed. Women had access to contraceptive methods that they could use, without the need for the cooperation of their male partners. This gave women, for the first time, power over their own sexuality and fertility. This allowed them to achieve one of the many components for changing the power relations between them and men and, thus, contributing to their equality.

But the dominance of the demographic imperative was associated with certain shortcomings. Fertility control by women was sometimes replaced by fertility control of women. Women were often considered as means and not ends, as delivery vehicles rather than full human beings. But then not all women benefited from new methods—the poor and the excluded were not reached or they were unable, for social and economic reasons, to access the services that provided family planning. Moreover, other health needs related to reproduction were neglected, if they had no demographic impact.

Cairo Consensus

These shortcomings were addressed head-on in Cairo. The Cairo Conference can be credited with the development and adoption of new concepts, with bringing sensitive issues to light, and with setting clear goals and targets to be achieved over a period of two decades.

Concepts of Reproductive Health and Rights

In Cairo, the concept of reproductive health was further refined and articulated. Reproductive health was identified as a development issue. And reproductive rights and, of course, women’s rights were recognized as fundamental human rights.

Reproductive Health

Just as a reminder, in Cairo, delegates agreed that reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. They agreed that reproductive health implies that people are able to have a satisfying and safe sexual relationships and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this last condition are the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice.

Governments agreed on the right of access to health care services to enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant, and also to ensure sexual health.

As a follow-up to the Cairo consensus, its fifth-year review at the June-July 1999 General Assembly special session at New York adopted Key Actions, which further clarified and expanded on the ICPD Programme of Action. In particular, paragraph 53 states: “Governments should strive to ensure that by 2015 all primary health-care and family planning facilities are able to provide directly or through referral the widest achievable range of safe and effective family planning and contraceptive methods; essential obstetric care; prevention and management of reproductive tract infections, including sexually transmitted diseases; and barrier methods, such as male and female condoms and microbicides if available, to prevent infection.”

May I ask you now, how many governments have achieved this comprehensive list of reproductive health actions? Our survey tells us some have, but others have not and we still have a long way to go.

Ladies and gentlemen,

This focus on reproductive health throughout the life cycle represented a breakthrough in population policy and in the human rights of women. It constituted a seismic shift away from a focus on demographics and numbers, to a focus on human beings and human rights, including reproductive rights.

Reproductive Rights and Empowerment of Women

Reproductive rights rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so. Reproductive rights rest on the basic right to attain the highest standard of sexual and reproductive health. It also includes the right to make decisions concerning reproduction free of discrimination, coercion and violence, as expressed in human rights documents. The ICPD Programme of Action states that the promotion of these rights for all people should be the fundamental basis for government and community supported policies and programmes for reproductive health, including family planning.

The whole issue of violence against women is central to women’s disempowerment. This has taken many forms, including sexual violence, which occurs at home and in the streets and in regions of military conflicts and wars. It further increases HIV/AIDS. Therefore, supporting women to say “NO” to sex to protect themselves is central to their empowerment and considering rape as a criminal act is also central to ensuring justice.

Sensitive Issues

The Cairo Conference took important steps forward in addressing sensitive issues that had not been addressed at the global level before. Sexuality issues were discussed. Female genital cutting was brought up from behind the stone walls of culture and social practices. The public health tragedy of unsafe abortion was no longer kept under the rug. And the reproductive health needs of adolescents and young people were openly debated. For the first time, the private issues where put on the public table for scrutiny by any one and every one. It was a daring act. But the ICPD also included a very important principle that allows for countries to take into consideration the implementation of the Programme of Action as it linked to national priorities and context, with due respect to religious beliefs and cultural values, but confirmed that these need to be taken within the larger human rights context. Such principle, in my view, would give space to diversity of approaches for implementation and would allow facilitating the implementation of the Programme of Action and the affirmation of human rights.

Goals and Targets

At the same time, targets for reproductive health indicators and for reproductive health services were set. And global goals for the allocation of resources, to achieve these indicators, were precisely outlined.

Ten Years after Cairo

Looking back 10 years after Cairo, we see that its concepts of reproductive health and rights have gained wide acceptance. The vast majority of countries have taken measures to integrate reproductive health into primary health care services, and to expand access to these services. Most countries have taken measures to adjust laws, policies or institutions to promote reproductive rights.

During the past decade, the concept of the reproductive health approach has been further elaborated. We now understand that it does not only imply doing different things. It implies doing things differently.

There is a shift in focus from a top-down approach to a bottom-up process that involves communities and empowers individuals. The empowerment of women and the involvement and men are critical to success. At the same time, sensitive issues have come under stronger light and more open discussion. Sexuality, female genital cutting and unsafe abortion are receiving wider attention as public health concerns. A noteworthy development is the release of Safe Abortion: Technical and Policy Guidance for Health Systems, by the World Health Organization.

For the first time, religious and cultural leaders receive information to speak out on sensitive issues and to promote concepts of reproductive health as being good for the women, the family, the community and the country. UNFPA started working with such community and spiritual leaders a long while ago. We have just documented this experience in a publication called Culture Matters and its summary in a brochure called Working from Within.

Women and Their Unmet Needs

Despite ICPD and the progress that was made, we still have data that make us worry greatly about reaching our targets by 2015. Today, 210 million women want to use contraceptives, but do not have access to such services. I would like to quote here again some figures many of you have heard, but they do show where we are. Every minute:

· 389 women become pregnant,

· 190 of these did not plan and do not wish to be pregnant,

· 110 women experience a pregnancy-related complication,

· 40 women have unsafe abortion,

· 1 woman dies from a pregnancy-related complication,

· 650 people become infected with a curable sexually transmitted infection, and

· 10 people become infected with HV, half of them women and young.

Even though I have heard these figures many times, they still shake me every time I hear them.

We see that reproductive health continues to elude millions of people due to inadequate levels of knowledge about human sexuality and poor quality reproductive health information and services. Reproductive health continues to be out of reach for many of the world’s people because of discriminatory social practices, negative attitudes towards women and girls, and the limited power many women and girls have in the social and economic spheres of their lives, including their sexual and reproductive lives.

Today, there is no health indicator that shows such a large gap between rich and poor nations as maternal mortality. Poor maternal health remains a leading cause of death and disability for women in developing countries. This is despite the fact that we have had success in countries as diverse as Bolivia, China, Egypt, Tunisia, Honduras, Indonesia, Jamaica and Sri Lanka. We know what works and what needs to be done, but we need to do it and on a large scale.

Young People and Reproductive Health

Today, half of all people on our planet are under the age of 25. The largest youth generation in history are entering their reproductive years. And the choices and opportunities they have, and the decisions they make, will shape our world for decades to come. Because young people are leaders today, the challenge we face is to support their leadership and participation also today.

Building on the general principle in all cultures and throughout civilizations that knowledge is empowerment and the basis for sound and informed decisions, we must expand all programmes to provide young people with reproductive health information and services to enable them to protect their health and their lives.

In today’s world of HIV/AIDS, reproductive health information and services are a matter of life and death. By denying such information and services, we are condemning young people to death. But, just as importantly, they are a matter of human rights. That is what the Cairo agreement and its fifth-year follow-up in 1999 have declared.

Since 1994, there has been significant progress in understanding the importance of addressing the rights and reproductive heath of adolescents. However, while progress has been made in providing youth-friendly information and services, this progress has been uneven among countries, and in many cases, is reaching only a fraction of the youth.

HIV/AIDS and the Challenge to Win the Fight

At the same time, AIDS, as a reproductive health disease in its widest social context, poses an unprecedented threat to development and to human beings and their families. As I said in the opening statement today, if greater action and an open public attitude are not taken to address HIV/AIDS in China and India – the two largest countries by many measures – as well as other affected countries, the epidemic could ravage Asia as it has done in Africa. There is no time or space for apathy or stigmatization. Governments and civil society leaders must take the fight to the open, speak about openly and find solutions for HIV/AIDS. Silence will only kill people and devastate economies and countries.

The integration of reproductive health and HIV/AIDS policies and programmes will save lives and money and scale up and speed-up most urgent effective responses. But we need to work closely with the two communities; the reproductive health and the AIDS communities.

While it is true that sexual and reproductive health is now seen as an integral component of the human right to health, the recognition of concepts has not always translated into action. Reproductive rights are still, in many areas, not respected, not protected and not fulfilled. Millions of people are denied access to reproductive health, and reproductive rights are violated on a regular basis

We know how to improve reproductive health: we know that we must:

· make motherhood safe,

· prevent HIV and AIDS,

· Support adolescent and young people,

· promote gender equality and the empowerment of women,

· provide reproductive health assistance in situations of conflict and natural disasters,

· secure reproductive health commodities, and

· prevent and treat fistula.

Let’s ask ourselves, are we doing what we know should be done?

Reproductive Health Commodity Security

We know that demand on reproductive health commodities will increase by 40 per cent by the year 2010 and, yet, we already have shortages right now. We know that while demand is increasing, resources for commodities are decreasing. Each year, we at UNFPA have a commodity gap of about $75 million dollars, just to respond to the immediate needs of the countries we serve. Therefore, we must be innovative and creative in securing new sources and ways of funding, as I mentioned in the opening statement. But, certainly, we know that some resource-poor countries and nations in conflict or in transition from conflict to development would not be able to afford to procure their own supplies. We, thus, need to see the international community translate its commitment and support of ICPD by ensuring stable resources for commodity security. Without these commodities, countries would not be able to achieve universal access to reproductive health by 2015 and, more importantly, the achievement of the right to choices would not be achieved. This is where South-South cooperation is a fertile area of joint work.

The Millennium Development Goals

There is also a new focus since Cairo—the Millennium Development Goals (MDGs). Though the MDGs do not refer to reproductive health by name, they do list improving maternal health as one of the eight goals. Reducing child mortality, promoting gender equality and empowering women, and combating HIV/AIDS are other MDGs, directly related to reproductive health. And there is wide agreement that the goal of eradicating extreme poverty and hunger is unlikely to be achieved if reproductive health is neglected.

United Nations Secretary-General Kofi Anan said: “The Millennium Development Goals, particularly the eradication of poverty and hunger, cannot be achieved if questions of population and reproductive health are not squarely addressed. And that means stronger efforts to promote women’s rights, and greater investment in education and health, including reproductive health and family planning.”

If we are to achieve the ICPD and MDG goals set for 2015, we need to run and run fast. UNFPA’s survey of 169 countries indicates that some of them will not meet the time-bound objectives. At the halfway point of the implementation of the ICPD programme, we see that some countries have done well and are progressing towards the desired goals and targets. Other countries, partly but not entirely for reasons beyond their control, have made little or insufficient progress.

What we have to understand regarding the challenge awaiting us as we walk out of Wuhan is the scaling up of responses and all its prerequisites. We need to look at how we can scale up our successes in each thematic area and their intersections and synergies — in poverty reduction, reproductive health, HIV/AIDS prevention, adolescent sexual and reproductive health, maternal and infant health, the empowerment of women, and partnerships. We have to learn how to scale up so that we can really have an impact that will help us achieve our goals.

Wuhan and Beyond

In looking forward to the next decade, in the countdown to 2015, we see challenges, but we also see opportunities.

Among the key challenges are:

Increasing the ranks of trained health care providers,

Improving the quality of care,

Ensuring a steady supply of reproductive health commodities,

More fully linking reproductive health and HIV/AIDS in areas where they naturally fit with one another, such as services for women and young people,

More fully involving young people and those living with HIV and AIDS,

Reaching the poor and marginalized segments of the population, and

Scaling up interventions to ensure universal access to reproductive health, as promised in Cairo.

But even with these challenges, there is ground for optimism. Women have mobilized and are speaking up for their rights. They still have some steep mountains to climb, but they are not turning around. Countries have declared in their regional meetings for ICPD at 10 that they own the ICPD agenda, that it has become part of their policies, laws, programmes and a blueprint for development. The South has taken control, hopefully a transformed and revitalized Partners for Population and Development will lead the way to South-South cooperation. And, as we will soon hear from China and Pakistan, two different experiences, which would hopefully show that investing in reproductive health yields tremendous returns—in human freedom, social progress and economic strength.

In this statement, I repeated the language of the Cairo agreement because it is so clear and pragmatic and, yet, it is visionary. And it remains the international standard, which we all strive to achieve.

Thank you.