The unfinished agenda for reproductive health: priorities for the next 10 years.

International Family Planning Perspectives A decade ago, at the International Conference on Population and Development (ICPD) in Cairo, representatives from 179 countries, including the United States, agreed that reproductive rights are human rights. They also recognized that the most pressing international problems—poverty, hunger, disease, environmental degradation and political instability—can be solved only by securing women’s sexual and reproductive health and rights. Today, the ICPD agenda is vigorously alive. In 2004, all 179 original governments reaffirmed this watershed agreement. At the same time, nearly 100 current heads of state, along with three dozen Nobel Laureates, numerous business and religious leaders and many others, signed an unprecedented World Leaders’ Statement in support of prioritizing the ICPD agenda.1 Since its presentation to the UN on October 13, 2004, the sponsors have collected even more signatures. Like the ICPD Programme of Action, this statement is a living document. As we go forward from Cairo’s 10th anniversary, it is vital not only to take stock of how far we have come, but to chart a course for where we are going. Given major global policy initiatives over the past 10 years, such as responses to the HIV/AIDS pandemic and the UN’s Millennium Declaration and Millennium Development Goals (MDGs), what must happen in the next 10 years to secure sexual and reproductive health and rights for all? What should our priorities be? In the last year or so, we have heard considerable naysaying regarding progress since Cairo. Granted, we have not made all the progress we hoped for, notably because of underfunding, destabilization caused by warfare and civil unrest, and the ravages of the HIV/AIDS epidemic. The glass, however, is half full, not half empty. Where policies, budgets and programs reflect ICPD priorities, we see important progress. More women have access to contraceptives than ever before and more girls are in school. In the past decade, contraceptive prevalence among couples has increased from 55% to 61%.2 Even in Africa, the region of the world where prevalence is lowest, contraceptive use among married women has risen from about 15% in the early 1990s to 25% today, and in Asia, it has risen from 52% to nearly 65%.3 Between 1998 and 2001, Brazil reduced maternal deaths from roughly 34 to 29 per 100,000 hospital admissions, through the efforts of the government and nongovernmental organizations (NGOs).4 In Bangladesh, thanks to a coordinated government and civil society initiative, the proportion of women receiving antenatal care rose from 26% in 1998 to 47% in 2002; during the same period, female life expectancy increased from 58 to 60 years, maternal mortality fell from 410 to 320 deaths per 100,000 live births, and the mortality rate for children younger than five dropped by 24%.5 And, contrary to some assertions, the family planning program there, long a success story, has not faltered.6 Progress extends to the policies of UN agencies. Sexual and reproductive ill health accounts for an estimated onethird of the global burden of illness and early death borne by women of reproductive age, and 20% for all people worldwide.7 In response, the World Health Assembly, in May 2004, adopted a strategy—based on the Cairo agreements— designed to accelerate progress toward reproductive health. The strategy, based on a human rights framework, focuses on the following five key action areas: strengthening health systems capacity; improving information for priority setting; mobilizing political will; creating supportive legislative and regulatory frameworks; and strengthening monitoring, evaluation and accountability.8 We can find positive examples from most countries, even those generally considered the toughest challenges. Take, for example, Nigeria. Soon after ICPD, a remarkable program—the Girls’ Power Initiative (GPI)—was begun in southeast Nigeria.9 Ten years later, GPI is an internationally recognized organization running a comprehensive program designed to achieve gender equality in four Nigerian states. By offering information about health and rights, and by helping girls develop the skills to protect themselves and to challenge pervasive inequalities, the organization is changing attitudes and behavior. Program participants are getting an education instead of getting married young; they have resisted genital mutilation for themselves and their sisters; and they are changing the way their parents, siblings, peers and communities value young women. In addition to the 1,500 girls directly involved in the program, GPI’s message of empowerment now reaches another 25,000 female students through programs at 28 participating schools. Because of their success, GPI and colleague organizations across Nigeria are influencing national policies that affect girls’ health and rights. The national government has adopted a national sex education curriculum and NGOs like GPI are helping implement it. Finally, many in the sexual and reproductive health community are concerned that the MDGs do not include the central ICPD goal: universal access to sexual and reproductive health by 2015. Yet, more than any other UN conference in the 1990s, the Cairo meeting provided a foundation for the MDGs. The eight MDGs are coincident with The Unfinished Agenda for Reproductive Health: Priorities for the Next 10 Years