UN Millenium Project- Public Choices, Private Decisions: Sexual and Reproductive Health and the Millenium Development Goals

Publication date: 2006

Public Choices, Private Decisions: Sexual and Reproductive Health and the Millennium Development Goals Achieving the Millennium Development Goals The UN Millennium Project is an independent advisory body commissioned by the UN Secretary-General to propose the best strategies for meeting the Millennium Development Goals (MDGs). The MDGs are the world’s quantifed targets for dramatically reducing extreme poverty in its many dimensions by 2015 – income poverty, hunger, disease, exclusion, lack of infrastructure and shelter – while promoting gender equality, education, health, and environmental sustainability. The UN Millennium Project is directed by Professor Jeffrey D. Sachs, Special Advisor to the Secretary- General on the Millennium Development Goals. The bulk of its analytical work has been performed by 10 task forces, each composed of scholars, policymakers, civil society leaders, and private-sector representatives. The UN Millennium Project reports directly to the UN Secretary-General and the United Nations Development Programme Administrator, in his capacity as Chair of the UN Development Group. By Stan Bernstein with Charlotte Juul Hansen 2006 Public Choices, Private Decisions: Sexual and Reproductive Health and the Millennium Development Goals Copyright © 2006 By the United Nations Development Programme All rights reserved This publication should be cited as: UN Millennium Project. 2006. Public Choices, Private Deci- sions: Sexual and Reproductive Health and the Millennium Development Goals. The UN Millennium Project was commissioned by the UN Secretary-General and sponsored by the United Nations Development Programme on behalf of the UN Development Group. The report is an independent publication and does not necessarily reflect the views of the United Nations, the United Nations Development Programme or their Member States. This publication was supported by Bill and Melinda Gates Foundation, The William and Flora Hewlett Foundation, Ford Foundation and The David and Lucile Packard Foundation. Front cover photo: TK Design: Communications Development Inc., USA, and Grundy & Northedge, UK Editing: Tina Johnson Layout and proofreading: Green Ink, UK (www.greenink.co.uk) Printing: Pragati Offset Pvt. Ltd, India Contents Foreword vii Preface ix Acknowledgements xi Acronyms xiii Executive Summary 1 Section 1: Introduction 21 ICPD and the MDGs – moving forward together 23 What is sexual and reproductive health? 24 Reproductive rights 26 Section 2: The current situation 31 The global burden of SRH-related diseases and risks 31 Measuring progress in key areas of SRH 34 Why hasn’t SRH been given higher priority? 47 Section 3: The impact of ensuring universal access to SRH and rights on achieving each of the MDGs 57 A contextual issue: population dynamics and progress on the MDGs 58 Goal 1: Eradicating extreme poverty and hunger 59 Goal 2: Achieve universal primary education 63 Goal 3: Promote gender equality and empower women 68 Goal 4: Reduce child mortality 74 Goal 5: Improve maternal health 78 Goal 6: Combat HIV/AIDS, malaria and other diseases 86 Goal 7: Ensure environmental sustainability 92 Goal 8: Global Partnerships 97 Boxes 1.1 Millennium Development Goals 22 1.2 ICPD definition of reproductive health 25 1.3 Reproductive rights as human rights 28 3.1 Reducing teen pregnancies can complement efforts to address barriers to gender equity in schooling 67 3.2 Access to family planning changes women’s lives 72 3.3 Improving family economies with microcredit and access to family planning 73 3.4 The three ‘stages of delay’ to seeking obstetric care 82 3.5 Obstetric fistula – a devastating condition caused by obstructed labor 83 3.6 Emergency contraception and the reduction of recourse to abortion 86 3.7 Population growth stresses natural resources 94 4.1 World Health Assembly resolution 58.31 107 4.2 Lessons from past experiences of integration 111 4.3 Special considerations for SRH 113 4.4 Integrating SRH services with those for HIV/AIDS 117 4.5 Mass media outreach in SRH 121 4.6 Quality of care increases contraceptive use 123 4.7 Missed opportunities to expand family planning services 126 4.8 ICPD recognizes adolescents’ rights to reproductive health 130 4.9 Factors that make health services youth-friendly 131 iv Contents Section 4: What needs to be done 103 Task 1: Integrating SRH analyses and investments into national poverty reduction strategies 104 Task 2: Integrating SRH services into strengthened health systems 108 Task 3: Systematically collecting data 118 Task 4: Acting on the Reproductive Health Quick Impact Initiative 119 Task 5: Meeting the needs of special populations 129 Requirements for effective action 137 Appendices 147 Appendix 1: Messages from the UN Millennium Project Reports 147 Appendix 2: MDG interventions by area as recommended by the UN Millennium Project 153 Notes 159 Bibliography 163 v 4.10 IPPF Rights of the Client 132 4.11 Meeting the special needs of married young first-time mothers: the IDEALS model 133 4.12 Breaking down barriers to contraception in Bangladesh 133 4.13 Encouraging men to be better partners 135 4.14 Dramatic demographic change within a decade: the case of Iran 138 4.15 The Navrongo experiment in Ghana: community health services 139 4.16 Involving communities in improving quality of care 140 4.17 The reproductive health resource estimates of the ICPD 141 Figures 2.1 Proportion of family planning desires satisfied for all contraceptive methods, by wealth quintile, survey periods – A: 1996–2004 and B: 1990–1995 39 3.1 Percentage of mothers aged 15–19 who dropped out of school due to pregnancy, by level of school attendance 66 3.2 Percentage of women aged 20–24 (who ever attended school) reporting pregnancy as reason for dropout 67 3.3 Under-five mortality by duration of birth interval in four countries 77 3.4 Share of total demand for family planning, interest in spacing and limiting by age cohort in Bangladesh (2004) and Kenya (2003) 80 3.5 Causes of maternal mortality, 2000 84 3.6 Relationship between restriction of abortion laws and maternal mortality 85 3.7 Annual expenditure for the four components of population activities as a percentage of total population assistance, 1995–2003 98 3.8 Population assistance by donor country per million US$ of gross national income (GNI), 2003 99 3.9 Final donor expenditures for population assistance, by geographical region, 2003 (total assistance US$3,846,900) 100 4.1 Costs of SRH in Uganda 2005–2015 106 4.2 Percentage unmet need for spacing among young people compared to total population, in 40 DHS low- and middle-income countries 121 4.3 Rates of unsafe abortion due to legal restrictions on abortion, 2000 127 4.4 Rates of maternal mortality due to unsafe abortion by legal restrictions on abortion, 2000 127 Contents vi Tables 1.1 ICPD quantifiable targets 25 2.1 Burden of disease estimates related to reproductive health, 1990 and 2001 33 2.2 Share of DALYs lost due to reproductive health-related causes, by region, 2001 (percent) 33 2.3 Countries where total fertility rate remains above five children per woman and has not decreased since 1960, selected characteristics, late 1990s 35 2.4 Age-specific fertility rates for women aged 15–19 by major region, 1995–2005 (per 1,000) 36 2.5 Average age at marriage and percentage of men and women aged 15–19 and 20–24 who are ever married 38 2.6 Estimates of maternal mortality ratios, maternal deaths and lifetime risk for 2000 43 2.7 Maternal deaths due to unsafe abortion 44 2.8 Trends in percentage of births attended by skilled birth personnel in 58 countries, 1990–2003 44 2.9 Knowledge of HIV/AIDS, men and women, in selected sub-Saharan African countries 45 2.10 Strengthening the MDG framework to measure women’s empowerment 50 3.1 Mother’s age and infant mortality 75 3.2 Countries with the highest HIV prevalence rate in adults, and HIV prevalence rate in young females and males, end 2001 89 3.3 Ratio of fertility rates among poor and non-poor urban women to fertility rates among rural women, by region 95 3.4 Predicted unmet need for married women aged 25–29 by rural–urban residence and, for urban areas, by poverty status (percentages) 96 3.5 Global domestic expenditures for population activities by region, 2003 (US$ thousands) 101 4.1 Projected costs for family planning and resulting savings in maternal and newborn care (2005–2015) (US$ millions) 105 4.2 Specific measures taken by 136 countries to integrate SRH in primary healthcare 109 4.3 Matrix on planning and monitoring integrated services 114 4.4 Illustrative service package for related SRH services 115 4.5 Revised total costs for achieving the ICPD Programme of Action 144 4.6 Costs of SRH service delivery in five UN Millennium Project case countries, HIV/AIDS excluded, (2005 US$) 145 Contents Foreword The world has an unprecedented opportunity to improve the lives of billions of people by adopting practical approaches to meeting the Millennium Develop- ment Goals (MDGs). At the request of the UN Secretary-General Kofi Annan, the UN Millennium Project has identified practical strategies to eradicate pov- erty by scaling up investments in infrastructure and human capital while pro- moting gender equality and environmental sustainability. These strategies are described in the UN Millennium Project’s report Investing in Development: A Practical Plan to Achieve the Millennium Development Goals, which was co- authored by the coordinators of the UN Millennium Project Task Forces. The Task Forces’ reports and Investing in Development, underscore the importance of sexual and reproductive health (SRH) for the attainment of the MDGs. Public Choices, Private Decisions: Sexual and Reproductive Health and the Millennium Development Goals takes these arguments further and presents the evidence of the relationship between SRH and each Goal. It underscores the urgent need to increase investments in improving the access to SRH infor- mation and services, particularly for the poor. Otherwise, the MDGs cannot be met. Public Choices, Private Decisions identifies and also describes the poli- cies and practical investments that can improve access to SRH services and information. Based on country experiences from around the world, the report shows how SRH analyses and interventions can be integrated into MDG- based national development strategies, as recommended by the UN Millen- nium Project. This report has been prepared by staff of the UN Millennium Project secretariat, who drew on background papers commissioned for this purpose. I am grateful for their important work and recommend this report to all who viii are interested in improving sexual and reproductive health outcomes that will make it possible to achieve the Millennium Development Goals. Jeffrey D. Sachs New York February 2006 Foreword The Millennium Declaration articulated a comprehensive call for development efforts to address poverty in all its dimensions by 2015. The vision of the Mil- lennium Summit is a deeply humanitarian one. The international community, including the experts associated with the UN Millennium Project, recognizes the Millennium Development Goals (MDGs) generated in the follow-up pro- cesses to the Millennium Summit as markers and priorities for the whole set of recommendations that emerged from the international conferences of the 1990s and early 21st century. The recent 2005 World Summit, which affirmed the centrality of the MDGs to international policy priorities and development discourse, also emphasized the broader development dialogue that is needed to ensure pov- erty elimination. It identified key issues, including reproductive health, that deserve greater attention in strategies to accelerate development. Sexual and reproductive health (SRH) is linked particularly to the attainment of the health MDGs, but it is also essential to gender equality and progress against poverty. In the Outcome Document of the 2005 World Summit (UN 2005b), the leaders of the world explicitly referenced these relationships in its Section II: Development. This report details the centrality of SRH to progress on human develop- ment. It necessarily builds on and reinforces the analyses and recommenda- tions made by the Task Forces of the UN Millennium Project. As we shall see, the concept of reproductive health is multidimensional and components of it are woven throughout the MDG framework: addressing demographically driven poverty traps under Goal 1; promotion of gender equality and empow- erment of women under Goals 2 and 3; safe motherhood and child survival under Goals 4 and 5; prevention (as part of a continuum of services) of HIV/ AIDS under Goal 6; population–environmental linkages under Goal 7; and Preface x international cooperation for equitable access to basic medical interventions under Goal 8. The major conclusions on SRH reached by the Task Forces are included in an appendix to this report. The main messages of the UN Millennium Project’s report, Investing in Development: A Practical Plan to Achieve the MDGs (2005a), are as important for SRH and rights as for other development areas. In all areas, the Project calls on countries to rephrase the question from “How close can we get to the Goals given current financial and other constraints?” to “Which investments and policy changes are needed to meet the Goals?” Domestic resource mobilization must be expanded to finance and ensure full and successful implementation of the MDGs, including SRH. At the same time, additional funding and aid effectiveness are needed to scale up investments in SRH and to ensure sustain- able improvements. And the national MDG-based development strategies that are to be developed in all countries should include access to SRH as a strategic factor to reduce poverty. In addition, global scientific initiatives are also crucial to strengthen the research agenda for SRH to further develop the evidence-based arguments for the linkages between improvements in SRH, poverty reduction and economic development. Many elements of this report, therefore, point to discussions already found in other reports prepared by the international experts associated with the Pro- ject. The purpose of this report is to elaborate some of the relationships, strate- gies for action and contexts that have advanced or impeded progress on SRH, and to come up with recommendations on what needs to be done to improve SRH as part of a strategy for human development. Section 1 of the report defines the concept of SRH and rights and brings out the linkages between the Programme of Action from the 1994 International Conference on Population and Development (ICPD) and the MDGs. Section 2 provides an overview of the state of SRH over time and across regions, high- lighting areas and groups – both within and between countries – that have had particularly adverse SRH outcomes. It also dissects why attention to access to SRH services is ‘falling short’. Section 3 shows how universal access to sexual and reproductive health and rights affects each of the MDGs. It reviews the available evidence linking SRH – directly or indirectly – to each of the Goals and highlights the magnitude of such impact as well as the pathways by which SRH acts to influence their achievement. Finally, Section 4 discusses the poli- cies, interventions and investments needed to ensure that all people have access to sexual and reproductive health and rights, and how such access should be explicitly included in national strategies to achieve the MDGs. Preface This report reflects a wide range of contributions, direct and indirect, and inten- sive discussions and exchanges with a large number of individuals in academic, non-governmental (advocacy and service), United Nations and donor organiza- tions active in the areas of population and sexual and reproductive health (SRH). In addition to these inputs the work has profited from the support of a large number of individuals and organizations. Only a small portion of those involved can be included here. Any important omissions are unintended. Thanks are offered to my colleagues in the UN Millennium Project Secre- tariat for the example they set in their work and for their openness to recogniz- ing and incorporating SRH in their work. Prime recognition is given to the leadership, inspiration and dedication of Jeffrey Sachs. At the Policy Advisor level, special thanks are due to Chandrika Bahadur, Eric Kashambuzi, Mar- garet Kruk, John McArthur, Joanna Rubinstein and Guido Schmidt-Traub. Members of the UN Millennium Project Task Forces and their research teams also provided invaluable assistance that contributed to the full body of SRH- relevant materials the project has produced. These colleagues include Debo- rah Balk, Carmen Barroso, Yves Bergevin, Nancy Birdsall, Andrew Cassels, Helen de Pinho, Alex de Sherbinin, Lynn Freedman, Tamara Fox, Adrienne Germain, Caren Grown, Geeta Rao Gupta, Joan Holmes, Barbara Klugman, Ruth Levine, Elizabeth Lule, Thomas Merrick, Vinod Paul, Allan Rosenfield, Bharati Sadasivaram, Gita Sen, Steven Sinding and Paul Wilson. Direct assistance and inputs came from the authors of the background papers prepared during the preparation of this report. These excellent con- tributors and colleagues include Javed Ahmad, Akinrinola Bankole, Judith Bruce, Erica Chong, Barbara Crane, Parfait Eloundou-Enyegue, Margaret E. Greene, Irina Haivas, Cynthia B. Lloyd, Susannah Mayhew, Manisha Mehta, Marc Mitchell, Julie Pulerwitz, Susheela Singh, Charlotte Hord Smith, Acknowledgements xii Michael Vlassoff and Deidre Wulf. Additional assistance in the development of tools relevant to the report recommendations and their implementation and in the provision of additional articles and inputs were provided by Oladele Aro- wolo, Rudolfo Bulatao, Howard Friedman, Richard W. Osborn, Jim Phillips and Eva Weissman. Editorial review and inputs were also provided by Garry Conille and Lindsay Edouard. Data and analyses relevant to the development and use of reproductive health indicators (and other intellectual stimulation and inputs) were provided by Carla AbouZahr, John Bongaarts, John Casterline, Trevor Croft, Ruth Dixon-Mueller, Attila Hancioglu, Kiersten Johnson, Vas- antha Kandiah, John Ross, Shea Rutstein, Lale Say, Florina Serbanescu, Iqbal Shah, John Stover, Mary Beth Weinberger and Charles Westoff. Advice, materi- als and support were also provided by Elizabeth Benomar, Eduard Bos, Thomas Buettner, Richard Cincotta, Lynn Collins, Barbara Crossette, Judith R. Bueno de Mesquita, Robert Engelman, Francois Farah, Duff Gillespie, Karen Hardee, Paul Hunt, Steve Kraus, Dima Malhas, John May, Sally Patterson, Kate Ramsey, Janneke Saltner, Joe Speidel and Hania Zlotnik. Additional appreciation is due to many UN system colleagues, including Paul De Lay, Helga Fogstad, Claudia Garcia-Moreno, Ralph Hakkert, Monir Islam, Ben Light, Edilberto Loaiza, George Martine, Zoe Matthews, Suman Mehta, Benson Morah, Monique Rakotomalala, Jagdish Upadhyay, Paul van Look and Tessa Wardlaw. Special gratitude is offered to Thoraya Obaid, Executive Director of the United Nations Population Fund (UNFPA), and the management of the Fund that loaned me to this effort. Additional thanks are offered to the support provided by Sono Aibe, Sarah Clark, Sara Costa, Jacqueline Darroch, Tamara Fox, Judith Helzner Blair Sachs and Sara Seims through personal contacts and the financial contribu- tions by the Foundations they serve: Bill and Melinda Gates Foundation, The William and Flora Hewlett Foundation, Ford Foundation and The David and Lucile Packard Foundation. Finally, special thanks are offered to Marianne Haslegrave, whose tireless and magnanimous efforts have made this opus possible and improved it. The report was edited by Tina Johnson under challenging circumstances. My dedicated research analysts, Charlotte Juul Hansen and Emily White Johansson, made invaluable contributions to this effort by both researching and writing specific sections of the report. This significant work deservedly earns them primary credit. Acknowledgements AGI Alan Guttmacher Institute AIC AIDS information centre CCA Common Country Assessment CCM Country commodity manager CDC Center for Disease Control CEDAW Committee on the Elimination of Discrimination against Women COPE Client-oriented provider-efficient DALY Disability-adjusted life year DFID Department for International Development, UK DHS Demographic and Health Survey FGC Female genital cutting FHI Family Health International GNI Gross national income HIMS Health Management Information System HIPC Heavily indebted poor country IASC Inter-Agency Standing Committee ICPD International Conference on Population and Development IEC Information, education, communication IMF International Monetary Fund INFO Information and Knowledge for Optimal Health IPPF International Planned Parenthood Federation IPT Intermittent preventative treatment IPV Intimate partner violence IV Intravenous M&E Monitoring and evaluation MAQ Maximizing Access and Quality of Care Acronyms xiv Acronyms MDG Millennium Development Goal MICS Multiple indicator cluster surveys MMR Maternal mortality ratio MTEF Medium-term expenditure framework NGO Non-governmental organization NIDI Netherlands Interdisciplinary Demographic Institute ODA Official development assistance OECD Organisation for Economic Co-operation and Development PAC Post-abortion care PRSP Poverty reduction strategy paper RTI Reproductive tract infection SRH Sexual and reproductive health STI Sexually transmitted infection SWAps Sector-wide approaches TB Tuberculosis TFR Total fertility rate TT Tetanus toxoid UN United Nations UNAIDS Joint United Nations Programme on HIV/AIDS UNDAF United Nations Development Assistance Framework UNDP United Nations Development Programme UN DESA United Nations Department of Economic and Social Affairs UNESCAP United Nations Economic and Social Commission for Asia and the Pacific UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund USAID United States Agency for International Development VCT Voluntary counselling and testing WHO World Health Organization YLD Years lived with disability YLL Years of life lost Executive summary Introduction Sexual and reproductive health (SRH) was given an international consensus def- inition at the International Conference on Population and Development (ICPD) in 1994. At its core is the promotion of healthy, voluntary and safe sexual and reproductive choices for individuals and couples, including decisions on family size and timing of marriage, that are fundamental to human well-being. Sexual- ity and reproduction are vital aspects of personal identity and key to creating fulfilling personal and social relationships within diverse cultural contexts. SRH does not only involve the reproductive years but emphasizes the need for a life-cycle approach to health. It touches on sensitive, yet important, issues for individuals, couples and communities, such as sexuality, gender discrimi- nation and male/female power relations. Attainment of SRH depends vitally on the protection of reproductive rights, a set of long-standing accepted norms found in various internationally agreed human rights instruments. The ICPD adopted the goal of ensuring universal access to reproduc- tive health by 2015 as part of its framework for a broad set of development objectives. The Millennium Declaration and the subsequent Millennium Development Goals (MDGs) set priorities closely related to these objectives. Progress towards the MDGs depends on attaining the ICPD reproductive health goals. The leaders of the world ratified that understanding in the 2005 World Summit Outcome Document (UN 2005b). The current situation A lack of access to SRH is a major public health concern, especially in develop- ing countries. For example, death and disability due to SRH accounted for 18 percent of the total disease burden globally and 32 percent of the disease burden among women of reproductive age (15–44) in 2001, though there is considerable 2 regional variation. Due in large part to the HIV/AIDS crisis, the reproductive health disease burden accounts for about one third of Africa’s total disease bur- den, which is almost double that of most other regions. And death and disability is only a portion of the impact of SRH on the quality of life and the prospects for development. The record of progress in SRH in recent decades is mixed. Fertility Although significant declines in fertility have occurred in most regions of the world, these have recently slowed in several countries. In many sub-Saharan African countries the fertility transition remains in its early stages. National level fertility declines also disguise significant variations within countries. Poor and rural populations often have the least access to family planning informa- tion and services, and thus the highest fertility rates. Adolescent reproductive health Adolescents, currently about 20 percent of the world’s population, have special reproductive health concerns and face risks related to early sexual experience, marriage and fertility. A rise in the age of marriage globally has contributed to declines in adolescent fertility. However, up to 50 percent of women in some countries still marry or enter a union by age 18, with this figure rising to 70 per- cent by age 20. The proportion of young women married or in union by age 20 is closely linked to adolescent fertility and exposure to reproductive health risks. Family planning Contraceptive use accounts for a substantial portion of the variation in observed fertility rates (others include age of marriage, abortion rates, post- partum amenorrhea and abstinence, and occurrence of marital separations). Although there have been dramatic increases in the use of family planning services, unmet need for family planning remains very high in low-prevalence regions. While contraceptive use among adolescents has been on the rise, data from 94 national surveys taken over the past decade demonstrate that the unmet need of adolescents is over two times higher than that of the general population in these countries. In this age group, unmet need for family plan- ning is predominantly a desire to delay pregnancy. Addressing these prefer- ences could reduce exposure to reproductive risks and empower young women in education, employment and social participation. Men are involved in reproductive health efforts as advocates for needed services, as supporters of their partner’s needs and as recipients of services for their health and well-being. The majority of men aged 20–24 report having had sexual intercourse before their 20th birthday, with a substantial proportion having had sex before their 15th birthday. A large proportion of married men aged 25–39, particularly in sub-Saharan Africa, say that they have not discussed family planning with their partners. Yet, men in many settings are more likely Executive summary Up to 50 percent of women in some countries still marry or enter a union by age 18 3 to approve of contraceptive use than their partners realize, and thus lack of com- munication leads to lost opportunities to cooperate on attaining preferences. In most countries a majority of men have only one sexual partner in any given year but a significant minority of married men has extramarital partners. Condom use is higher among unmarried men than married men as within marriage this is associated with unfaithfulness and mistrust of the spouse. Maternal health Some 529,000 women die each year in delivery and pregnancy – the over- whelming majority in developing countries. While women in industrialized countries face a 1 in 2,800 chance of dying in pregnancy or delivery, the risk in developing regions is 1 in 61. In sub-Saharan Africa it is as high as 1 in 16. This lifetime risk of death reflects both pregnancy rates and the qual- ity of delivery care associated with each pregnancy. Maternal deaths occur from both direct and indirect complications. Direct complications account for 80 percent of maternal deaths and include hemorrhage, sepsis, hypertensive disorders from pregnancy, abortion complications and obstructed labor. Indi- rect complications vary from region to region and include malaria and AIDS. Moreover, it has been estimated that for every woman who dies, approximately 30 more suffer injuries, infection and disabilities in pregnancy or childbirth. These disabilities include obstetric fistula. Unsafe abortions contribute to 13 percent of maternal deaths, about 68,000 per year. Abortion-related complications contribute to a relatively large share of maternal deaths in Latin America and the Caribbean (where legal restrictions on abortion are common) and to a lesser degree in Asia and Africa. The case fatality rate for abortions, however, is highest in Africa. Increases in the proportion of births assisted by a skilled birth attendant have been dramatic in Southern Asia, Eastern Asia and the Pacific and (from higher initial levels) in Latin America and the Caribbean. Sub-Saharan Africa lags behind other world regions with only 41 percent of births assisted by a skilled attendant. This contributes to the high maternal mortality on the continent. HIV/AIDS and STIs The HIV/AIDS pandemic constitutes a major threat to development in affected countries. The virus is spreading through different populations at varying rates, and prevalence rates among adults range from a fraction of a percent to well over 30 percent. In sub-Saharan Africa and parts of the Carib- bean, the epidemic is clearly established in the general population and is largely spread through heterosexual contact. Whatever the main means of transmis- sion, however, it is almost always the poor and the marginalized that are at greatest risk of exposure. More than half the men and women in most coun- tries worldwide lack comprehensive and correct knowledge on how to prevent HIV transmission. Executive summary Unsafe abortions contribute to 13 per cent of maternal deaths, about 68,000 per year 4 The prevalence of curable and incurable STIs, including HIV/AIDS, is higher in sub-Saharan Africa and in Latin America and the Caribbean than in other regions. In some parts of the developing world, men may be prepared to use condoms but are unable to obtain them, especially young men and those with limited resources or living in rural areas. Gender-based violence Gender-based violence is a significant public health problem that affects mil- lions of women worldwide. Abused women have been found to be more than twice as likely as non-abused to have poor health, including reproductive health, and both physical and mental problems. These women also have an increased risk of contracting an STI, including HIV/AIDS. Why hasn’t SRH been given higher priority? The importance of SRH to the attainment of international development goals has not been adequately translated into action frameworks and monitoring mechanisms at international, regional and national levels. Advances have been hindered by the complexity of the concept. Different components of SRH fall within the province of different sectoral ministries, challenging coordinated national responses. Many national planners learned development economics before the recent analytical advances on the effect of age structures on poverty reduction. SRH issues have also been distributed among various MDGs (mater- nal health, child mortality, gender equality, HIV/AIDS) and family planning has been excluded from the Goals, reducing priority attention. The diverse justifications for the importance of attaining SRH relate to public health, human rights, moral priorities, instrumental concerns related to basic development goals (including linkages and relationships) and institu- tional analyses. However, different groups and constituencies focus on differ- ent elements of this complex of concerns, complicating resolution and political mobilization. Operational planning often takes place in settings that do not welcome or encourage the resolution of these contending vocabularies and pri- orities. Matters related to sex and reproduction are sensitive – enmeshed in issues of culture and ideology of social institutions and personal identities. In many countries, various cultural groups have different understandings and positions on SRH (and on associated service provision). Public discussion and attention may be limited so political divisions can be avoided or because there is stigma attached. SRH has only become a fit topic for international discus- sion and consensus within the last 10–15 years. The targeted time frame for the MDGs also diverts attention from the SRH agenda. The targets and indicators in key areas such as gender equality are defined consistent with what can be measured and with change in short time periods, not in the longer time horizons needed for cultural change and demographic shifts. Further, issues related to women have been accorded low Executive summary Gender-based violence is a significant public health problem that affects millions of women worldwide 5 priority. Gender disparities in education have not been achieved on time. Maternal mortality has not been given appropriate priority and investment. Priority-setting approaches in the area of health have slighted SRH concerns. A disease-oriented approach to health priority setting has not recognized the importance of preventing unintended pregnancies. The consequences of these extend beyond the direct individual disability concerns to social participation, familial health and complex empowerment issues. Returns to investments in SRH are, therefore, difficult to assess and often omitted from policy dialogues. The historical record of progress in SRH, particularly in the expansion of contraceptive use and the overall reduction in fertility, has diverted con- cern from continued investment needs. The assumption of continuing prog- ress along historical paths has reduced the expenditures needed to attain it. Changing demographic concerns (e.g., the reductions in fertility and increased pace of population ageing) in major donor countries have also undercut some support for developing country initiatives. With donor development assistance policies moving towards direct budget support without earmarks for specific programs, areas like women’s health can be neglected. Vertical pipelines for specific initiatives (e.g., HIV/AIDS) can give priority to some interventions but harm health system capacity building. Within developing countries, health sector reform, often including decen- tralized priority setting, increases the information and advocacy burden for inclusion of SRH concerns. Central functions (like operating logistic systems and service quality control) require high-level commitment and a supportive policy and regulatory framework. The international discussion on SRH emphasizes an outcome-oriented public health approach but people react to multiple dimensions. Strong pas- sions and intensive debates continue on a range of issues: abortion, adolescent SRH and even family planning. These issues elicit renewed discussion at every relevant intergovernmental conference. Donor policies can advance or stifle discussion and reproductive health program development. An example of the difficulties in addressing SRH concerns comes from the response to HIV/AIDS. Despite the dominant role of sexual transmission in its spread, it is classified with communicable diseases (tuberculosis and malaria) in the MDG framework. A historical separation of STIs (including HIV/AIDS) and other reproductive health issues (including family planning) has only recently started to be addressed in policy, programs and funding priorities. The impact of universal access to SRH on attainment of the MDGs Apart from being important in and of itself, ensuring universal access to sexual and reproductive health and rights is instrumentally important for achieving many of the MDGs. The achievement of the MDGs is influenced by popula- tion dynamics such as population growth, fertility and mortality levels, age Executive summary A disease- oriented approach to health priority setting has not recognized the importance of preventing unintended pregnancies 6 structure and rural–urban distribution. Each developing country has its own unique combination of demographic factors that affect the prospects for prog- ress toward the MDGs. Creating economic development is connected to increasing productivity and investments in areas such as education, nutrition and health. Population momentum joined with declining fertility rates provides a unique chance to spur economic development as the work force increases and the dependency burden of society decreases. However, this requires policies that create jobs for the growing work force. The young age dependency burden in the least devel- oped countries and regions creates expanding demands for resources to and investment in education, nutrition and health just to keep pace with popula- tion growth. The projected declines in birth rates, should adequate resources help realize them, will allow greater investment in quality improvements. Until the HIV/AIDS epidemic, mortality levels were expected to continue to decline in all regions. However, this tendency has been reversed in coun- tries where HIV/AIDS is most prevalent, especially in sub-Saharan Africa. Life expectancy at birth is lower in the developing regions than in the more developed regions but it is projected to increase in both less and least develop- ing countries. This is dependent on successful implementation of HIV/AIDS prevention and treatment programs and on other health interventions. Migra- tion, both internal and international, also conditions the prospect for progress towards the MDGs. Goal 1: Eradicating extreme poverty and hunger Population trends affect the course of and prospects for poverty reduction. Diverse and changing population dynamics have had dramatic impacts in sev- eral world regions. Sub-Saharan Africa remains in a poverty trap where demo- graphic factors – high fertility, high infant and child mortality, and excess adult mortality (including that due to HIV/AIDS) – play significant roles. Eastern Asia, on the other hand, has seen dramatic declines in the number of persons living in income poverty. Recent analyses suggest that 25–40 per- cent of economic growth is attributable to the effects of decreased mortality (health affects productivity) and declining fertility (allowing a deepening of human capital investment). At the societal level there is a remarkable one-time opportunity when the proportion of the population of labor-force age (15–60) is large relative to the more ‘dependent’ younger and older populations. This demographic bonus, though, is not guaranteed. It is an opportunity and a challenge that depends on the right priorities, policies and strategies. When institutions exist that permit the accelerated flow of information throughout a society it is possible to have wide dissemination of informa- tion about the benefits of smaller families, accurate feedback of the returns to investments in children and quicker recognition of the increased chances of children surviving, which reduces old age support motivations for persistent Executive summary Population trends affect the course of and prospects for poverty reduction 7 high fertility. However, the largest difference between rich and poor families is not in their desired or ideal family sizes but in their ability to implement their preferences. Access to services for the poor can be adversely affected by clinic placement, hours of service and user fees. The demographic bonus therefore operates not just on a macroeconomic level but also at the micro levels of the community and family. High levels of fertility contribute directly to poverty, reducing women’s opportunities, diluting expenditure on children’s education and health, precluding savings and increasing vulnerability and insecurity. SRH programs can help improve the nutritional status of women and their children and advance progress on the hunger and maternal and child health targets. Supplemental feeding programs for pregnant women, improving wom- en’s knowledge of the nutritional requirements of themselves and their children and increasing women’s power to negotiate access to needed nutrition must be part of a multi-intervention strategy. Closely spaced pregnancies and the associated high fertility levels place women at an increased risk of anemia and other conditions of absolute and relative malnutrition. Progress in alleviating hunger also requires targeted inputs to improve agri- cultural productivity. Community level cooperative action can ensure imple- mentation of soil improvement, improved water management and other com- ponents of an integrated approach to agricultural productivity. However, rapid population growth fueled by high fertility desires and/or poor implementation of preferred family sizes can lead to the sub-division of land holdings, which can reduce the benefits of productivity-enhancing interventions. Goal 2: Achieve universal primary education SRH impacts various levels of education in similar and overlapping ways. For example, girls may be pulled out of school to care for siblings at any time during their education. This is more likely as family size increases. Preg- nancy-related dropouts, too, may occur at any level of education, including the primary level. Many empirical studies have found that a child’s school attendance is negatively associated with the number of siblings with whom the child lives. There is a strong incentive for larger families to keep children, especially girls, at home and out of school. There is also evidence from these studies that the gender gap in education may be explained by parental preference for sending boys to school when a family has limited resources. Gender disparities in education, then, should decrease with falling family sizes. Yet, the estimated effects are often relatively small in size compared to other factors: Parental schooling accounts for a substantial proportion of the increase in rates. As States increasingly subsidize education, the impact of parental resources on younger children’s school enrolment becomes less important. However, educational attainment has been found to be linked to family size, as older children are increasingly likely to be pulled out of school due to costs Executive summary There is a strong incentive for larger families to keep children, especially girls, at home and out of school 8 of schooling and their increasing ability to contribute to household responsi- bilities. Greater investments in children’s welfare, including schooling, often occur in households where mothers have greater control over spending. Adolescents and youth in developing countries are having sexual encoun- ters at an early age. The increased gap between onset of menses and mar- riage also increases exposure to pregnancy risk. A growth in the percentage of girls attending school after puberty inevitably leads to a rise in the risk of pregnancy among students. There is a high cost associated with becoming known to be pregnant while still in school. A pregnant schoolgirl often has to choose between dropping out or undergoing an abortion that is typically illegal, and therefore likely to be unsafe. Boys who are involved in girls’ preg- nancies do not face these same risks. Reductions in pregnancy-related drop- outs would make a large enough difference to warrant policy attention, with payoffs that are likely to be greatest, in countries that have begun to address gender discrimination and in those at intermediate levels of socio-economic development. Early marriage is also associated with teen pregnancy. Married young girls, compared to their unmarried counterparts, have limited social networks, are less mobile, have less income-generating opportunities, face heightened exposure to health risks and have higher levels of overall fertility. Goal 3: Promote gender equality and empower women Ensuring universal access to sexual and reproductive health and rights is essen- tial for achieving gender equality. Involving men in SRH is crucial to promot- ing gender equality and to increasing men’s reproductive health. Guaranteeing SRH and rights is important to ensure that girls and women lead longer and healthier lives, and has strong and direct impacts on their well- being. SRH services work to promote voluntary, safe and healthy sexual and reproductive choices. To do this, they must go beyond simply making avail- able family planning information and services and include such activities as combating gender-based violence, sexual coercion and female genital cutting (FGC). Gender-based violence, in particular, has a profound impact on the well- being of women. It takes many forms: coerced sex in marriage and dating relationships, rape by strangers, systematic rape during armed conflict, sexual harassment, sexual abuse of children, forced prostitution and sex trafficking, child marriage and violent acts against the sexual integrity of a woman (such as FGC or virginity inspections). Sexual violence is associated with significant emotional trauma and long-term mental health problems. Sex trafficking is a growing problem. Some 800,000 people are trafficked across borders each year, and 80 percent of them are women and girls who are bought and sold worldwide mostly for commercial sex. This figure does not include the substantial number of women and girls who are trafficked within their own country. Executive summary Involving men in SRH is crucial to promoting gender equality and to increasing men’s reproductive health 9 It is estimated that between 100 and 140 million women and girls, most of them in Africa, the Arab States and Asia, have undergone FGC. This rite of passage may cause hemorrhaging, infection and even death, and exposes young girls to serious and lasting physical and emotional trauma. Long-term chronic health risks include constant urinary tract infections, reproductive tract infec- tions and more severe menstrual pain. Finally, the ability to experience plea- sure from sexual encounters is largely destroyed. Early marriage takes many different forms and has many different causes, including age-old traditions, protecting girls from unintended and out-of- wedlock pregnancies or building ties between families or communities. How- ever, marriage of girls by coercion or before they are old enough to give full and free consent is not only harmful to their health and well-being; but it also violates their human rights, as elaborated in the Universal Declaration of Human Rights and other human rights instruments. Allowing a woman to satisfy her desire for spacing or limiting children enables her to better balance household responsibilities (including childrearing) with activities outside the home, including economic, political and educational activities. One of the most dramatic transformations in development over the past 30 years has been women’s increasing role in the labor force, greatly cata- lyzed by their ability to control their fertility and thus to shape their careers over their lifecycle. Goal 4: Reduce child mortality Maternal behavior and fertility are important determinants of child health and survival. Children born to very young mothers are at an increased risk of suffering complications. Similarly, children born too closely together are also at an increased risk of ill health. Where modern contraceptive prevalence is below 10 percent, the average infant mortality is 100 deaths per 1,000 live births. Where prevalence is 10–29 percent, infant mortality is 79 per 1,000; and where it is over 30 percent, it is 52 per 1,000. Children born to teen mothers are twice as likely to die during their first year of life as those born to women in their 20s and 30s. Young teen mothers are at higher risk of experiencing serious complications because their bodies often have not yet fully matured. They are also much more likely to have poorer nutritional habits and are less likely to seek adequate antenatal and post- partum care, leading to higher rates of low birth weight, malnutrition and poor health outcomes in their children. Birth spacing is an important lifesaving measure for both mothers and children. Compared with babies born less than two years after a previous birth, children spaced three or four years apart are more likely to survive to age five. In less developed countries, if no births occurred within 36 months of a pre- ceding birth the infant mortality rate would drop by 24 percent and the under- five-mortality rate would drop by 35 percent. In total numbers this would Executive summary Children born to very young mothers are at an increased risk of suffering complications 10 annually amount to 3 million children under age five, or roughly 30 percent of total child mortality. Furthermore, a minimum of three years birth spacing is also important for enhancing the child’s cognitive and social development. Women who have closely spaced births are more likely to discontinue breast- feeding too early, thereby increasing the risk of infant mortality. Breastfeeding protects babies and infants from infectious and chronic diseases – including both diarrhearal and acute respiratory diseases – and helps them to recover more quickly from illness. Intensive demand feeding also provides protection against pregnancy immediately after a birth by delaying the return of menses. The promotion of exclusive breastfeeding is an important global priority for increasing the health of infants. An HIV-positive mother may reduce the risk of postnatal HIV-transmission when she exclusively breastfeeds her child as compared to giving mixed feeding. Goal 5: Improve maternal health Each year more than half a million women die of preventable complications of pregnancy and childbirth. Making access to SRH more widespread could decrease childbirth- and pregnancy-related mortality and morbidity. That women die of preventable causes during childbirth is a tragedy. This tragedy is compounded when the pregnancy was not even intended. Moreover, as the Task Force on Child Health and Maternal Health asserts, improving mater- nal health requires policies and interventions that go beyond simply reducing maternal mortality. About 201 million women have an unmet need for modern contracep- tion – making it more likely that they will experience high-risk or unintended pregnancies and thus complications in pregnancy, during childbirth or from an unsafe abortion. Among married women of childbearing age, demand for birth spacing represented 33–75 percent of demand for family planning ser- vices. Younger women especially want to delay their next pregnancy and have longer birth intervals. Some are also interested in delaying their first birth despite the common assumption that women want to have their first child right after marriage. The failure to help women fulfil their spacing desires derives from socio-cultural constraints on women’s status and on other restric- tions on access to health services. Comprehensive basic and emergency obstetric care is essential to maternal mortality reduction. Although there has been progress over the past decade, only about 70 percent of births in developing countries are preceded by even a single antenatal care visit. Anemia during pregnancy and childbearing increases the risks of maternal mortality and morbidity and also adversely affects infant health by increasing odds for prematurity and low birth weight. Reductions in delays to providing emergency care (in the decision to seek it, in arriving at a facility and in receiving care on arrival) can dramatically improve survival out- comes. Post-partum care, often less available than antenatal care, contributes Executive summary That women die of preventable causes during childbirth is a tragedy. This tragedy is compounded when the pregnancy was not even intended 11 to the health and survival of the newborn and provides an opportunity for family planning counseling. High rates of unintended pregnancies are associated with higher incidences of abortion, and specifically unsafe abortions, which further place women at risk of death and disability. Young women are particularly impacted, as two out of every three unsafe abortions are experienced by 15–30-year-olds and 14 percent by women under the age of 20. Legal abortion, however, does not guarantee safety in places where providers are not trained or barriers prohibit broad access to services. Evidence points to a strong correlation between abor- tion laws and policies, safer abortion and reduced maternal mortality. Lack of use of or access to contraceptives is a major cause of unwanted pregnancy: More than half of all women in the developing world are at risk because they are using a traditional method with high failure rates, they are using a reversible method that requires regular supplies, or they are using no method at all. Correct and consistent use of contraception and access to emer- gency contraception can significantly reduce recourse to abortion and improve maternal health overall. Goal 6: Combat HIV/AIDS, malaria and other diseases Addressing SRH needs and combating AIDS, malaria and other diseases require essential medicines to be available throughout a country. Globally, 80 percent of HIV cases are transmitted sexually. Only one in five people at risk of contracting HIV have access to even basic prevention services, which could prevent 29 million of the 45 million new infections projected to occur in this decade. Testing, counseling, treatment and care reach an even smaller propor- tion of those affected. Correct and consistent use of condoms – which has been found to reduce HIV incidence by 80 percent – is a key component of any national prevention strategy used to reduce sexual exposure to HIV. Other components include delaying sexual initiation, abstinence and reducing the number of sexual part- ners. However, there is still a wide gap in condom availability in many develop- ing countries, and large-scale investments will need to be made in education and awareness programs that promote and de-stigmatize condom use among both men and women. Underlying power dynamics between women and men in many develop- ing countries also prevent women from accessing condoms and then insist- ing on their use. Unprotected sex with a non-monogamous husband greatly increases a woman’s likelihood of being exposed to HIV. An important step in addressing such power dynamics is to ensure that there is universal access to sexual and reproductive health and rights, and that family planning services actively target men in their programs. SRH services include counseling (for both women and men) to reduce exposure to risky sexual behavior that may increase a person’s chances of contracting HIV (or transmitting it to others). Executive summary Only one in five people at risk of contracting HIV have access to even basic prevention services 12 In 2003, an estimated 630,000 infants worldwide became infected with HIV during their mother’s pregnancy, labor or delivery, or as a result of breast- feeding. Many of these infections could have been avoided by ensuring moth- ers’ access to a regimen to prevent mother-to-child transmission. Expanded SRH services can provide an integrated package of services including counsel- ing on HIV transmission and prevention, psychological and social support, and antiretroviral treatment for HIV-positive mothers. Voluntary contracep- tive services to help HIV-positive women prevent unwanted pregnancies should be a central component of cost-effective national prevention strategies. Prevention and treatment of STIs, while important in their own right, are also essential components of strategies to reduce HIV transmission. Women are more likely to suffer complications from STIs as they are more often asymptomatic and are less likely to seek treatment even when experiencing symptoms. Women with STIs are also more likely to experience stigmatiza- tion, infertility, and even abuse and abandonment. Pregnancy reduces women’s immunity to malaria, which can then lead to adverse health outcomes, and even death, for the mother as well as increased risks of stillbirth or low birth weight and its related complications for the infant. HIV-positive women experience higher frequency and density of para- sitemia, and women who are co-infected have more anemia and more adverse birth outcomes than women infected with either malaria or HIV alone. Ensur- ing universal access to SRH services would help ensure that pregnant women at risk of malaria receive effective treatment. Goal 7: Ensure environmental sustainability The past century of population growth has put increasing pressure on natural resources as the scale of human needs and activities has expanded. Population growth, among other factors, has led to cropland expansion, intensified farm- ing, housing sprawl and overuse of water and forests. Population growth is an indirect driver of environmental degradation. It is part of a complex dynamic that includes poverty, inequality, levels of con- sumption and policy and market failures. Populations living in countries with scarce natural resources and the fewest resources to invest in health, education and family planning are growing more rapidly than the world population as a whole, putting even greater pressure on these often biologically fragile zones. Environmental sustainability must be a result of biological conservation programs, technological advancement and a broad human development effort. Development priorities need to include investments in education and health, including SRH, to break vicious cycles of population growth and environmen- tal vulnerability. The world’s urban population is estimated to grow from 2.1 billion in 2000 to 5 billion in 2030. Slowing the growth of new slums and improving the lives of slum dwellers require urgent action. The urban poor require SRH Executive summary Expanded SRH services can provide an integrated package of services including counseling on HIV transmission and prevention, psychological and social support, and antiretroviral treatment for HIV-positive mothers 13 services within an accessible and functioning health system. While the fertility rate of rural women is generally higher than that of urban women, poor urban women have significantly higher fertility rates than non-poor urban women. The unmet need for contraception among the urban poor is also higher than among the urban non-poor, though lower than that of people in rural areas. Maternal mortality is generally higher in rural areas than in urban areas. Both rural and poor urban populations lack access to modern health insti- tutions. However, while rural populations are most affected by proximity of service, urban populations face other factors, including transport costs and user fees. Many improvements are needed for slum dwellers and the urban poor to increase their SRH outcomes. HIV/AIDS is a major health concern in cities and some risks are heightened there. Adolescents may also face greater challenges to leading healthy sexual lives. Goal 8: Global partnerships The International Conference on Population and Development (ICPD) was the first international conference to estimate the resources needed to achieve the agreed action plan. The resource estimates included four components: family planning; reproductive health; STIs and HIV/AIDS; and basic research, data and population and development analysis. Each component should be inte- grated into basic national programs for population and reproductive health. It is important to recognize that the Programme of Action estimates did not include all the issues brought up at the conference, and that additional resources are still needed for other objectives and goals (later incorporated in the MDGs) like the improvement of women’s status and empowerment and the strengthening of primary healthcare systems However, the resources mobilized from donors are not even living up to the funding targets that were agreed at the ICPD. Although funding for popula- tion activities is increasing, this is largely due to a higher resource flow towards HIV/AIDS activities. Unfortunately, this has happened at the expense of other areas within population assistance. Family planning has received less and less attention since the ICPD, and its funding as a share of total population assis- tance dropped from 56 percent in 1995 to 13 percent in 2003. Donor countries vary in how much of official development assistance (ODA) they contribute to population activities. In 2003, only five countries gave more than the 4 percent of ODA to population activities (as agreed at ICPD). Population activities in developing countries also receive external assistance from supporters other than donor countries. Development banks, especially the World Bank, foundations and non-governmental organizations (NGOs) contribute important resources. Out-of-pocket expenses contribute a large amount of the total domestic financial resources. Even though domes- tic expenditures are increasing, many developing countries (and particularly the poorest countries) require adequate ODA. Within the time frame for the Executive summary Maternal mortality is generally higher in rural areas than in urban areas 14 MDGs they cannot reach a level of sustainable domestic funding anywhere near two thirds of the costs for population activities. Providing access to reproductive health drugs and supplies is crucial to the achievement of the MDGs and to the improvement of health in developing countries. Reproductive health commodity security is about ensuring a secure supply and choice of commodities such as contraceptives (including condoms), maternal health supplies and those needed for HIV/AIDS and other STI treat- ment and prevention. These commodities need to be provided to rural and urban populations, rich and poor, young and old, and both women and men. It is crucial that national capacity is developed in order to secure sustainable forecasting, logistics, financing, procurement, warehousing, stock monitor- ing, distribution of commodities, and training and management of human resources. What needs to be done The incorporation of SRH into national strategies to attain the MDGs and into international and regional programs has been recommended by the world’s leaders in the 2005 World Summit Outcome Document (UN 2005b) and in health sector recommendations at the World Health Assembly. Political will for action and the close monitoring of progress can accelerate advances. Political will should be shown by both high-level commitments that legitimate priorities and the mobilization of community support. Task 1: Integrating SRH analyses and investments into national poverty reduction strategies National development planning must be based on MDGs needs assessments that include population and SRH concerns. Such analyses need to diagnose the current situation and the projected dynamics of key population groups receiving priority interventions in order to orient investments to reach coverage targets and reflect their expected returns. To date, these issues have not been adequately incorporated in planning exercises, and existing national population or SRH strategies have not been appropriately referenced. Yet, investments in voluntary family planning pro- grams, for example, would reduce the total resource requirements for progress on the health-related MDGs and provide additional benefits. The selection of indicators to monitor progress on SRH at national, regional and global levels can help focus action priorities. Task 2: Integrating SRH services into strengthened health systems Family planning programs started as vertically organized systems with distinct donor funding guarantees. This provided some advantages and disadvantages. The ICPD placed all SRH services – including family planning – within the regular health system. Countries subsequently changed their programs to Executive summary Political will for action and the close monitoring of progress can accelerate advances 15 increase the integration of these services into the primary healthcare system. A systematic framework for approaching integration is needed to guide pro- gram design and monitor operations. Attention to a person-centered continuum of care over a lifecycle and to service interventions is proposed as a guiding framework. Effective informa- tion and referral systems, and well-equipped and functioning component ser- vice delivery units, are essential to ensuring this standard of care. Past experience with service integration points to the need for more man- agement expertise. Monitoring and evaluation and accountability burdens increase with service completeness and complexity. Appropriate attention must be given to SRH, the retention and strengthening of specialized capabilities and the improvement of logistics and procurement systems. SRH interventions can be allocated to different actors both within and outside the clinical health system. Effective integration requires giving priority to meeting client needs, cli- ent-focused information, realistic and specific planning and monitoring, and flexible management of motivated and competent staff in strong health sys- tems. SRH issues pose special challenges since needs over the life cycle and among different populations vary greatly, and services at different levels of the health system need to be provided and linked. The effective integration of SRH delivery with HIV/AIDS prevention, treatment and care systems is a requirement for accelerated progress on the full range of SRH concerns. Task 3: Systematically collecting data Effective management of integrated health service delivery, including SRH components, requires investments in service and results-oriented databases. Such system development has been challenging in many settings. Beyond health management information needs, there has been a lack of basic informa- tion that stakeholders can use to ensure accountability related to a variety of population and SRH concerns. These include reproductive health and educa- tion within the socio-cultural context for sexual and reproductive behavior; population dynamics and youth needs; urbanization and migration; deteri- orating rural and agricultural conditions; poverty pockets; gender roles and relationships and belief systems; and gender-disaggregated data to provide a more accurate picture of women’s economic contributions to society, includ- ing their management roles and their unpaid labor in the family and in the informal sector. Strategic interventions to improve data for decision-making and account- ability include the definition of a basic package of health information needs, negotiation of effective accountability mechanisms between donors and national authorities, formalized linkages between government agencies and national stakeholders (NGOs and national research institutions) and Executive summary SRH issues pose special challenges since needs over the life cycle and among different populations vary greatly 16 investments in improving the technical capacity of those involved. Such developments should attend to the specific needs at national, regional and district levels. Task 4: Acting on the Reproductive Health Quick Impact Initiative The UN Millennium Project has identified key interventions to accelerate progress towards achieving the MDGs as a whole that can produce results within relatively short time frames. The Reproductive Health Quick Impact Initiative has two components: (1) improving access to reproductive health information and services, including family planning, and (2) closing the fund- ing gap for commodities, supplies and logistics. Knowledge about family planning is now fairly widespread, but important misconceptions and information gaps remain about this and other SRH issues. These are particularly pronounced among young people and include lack of knowledge about the transmission of HIV/AIDS. Reasons for non-use of services are various and context-specific. Solutions must be tailored to national circumstances as there are no ‘one size fits all’ methodologies. In addition to addressing unmet need for family planning, the quality of care needs to be improved. This includes attention to providing a range of choice of methods, meeting information needs, availability of techni- cally competent staff and equipped facilities, adequacy and sensitivity of cli- ent-provider relations, continuity-encouraging follow up, and provision of an integrated constellation of services. The quality of SRH care leads to greater acceptance of contraceptives and other SRH services and lower rates of discon- tinuation. The increased use of community-based health workers providing a range of service modules will require extensive training and backstopping to ensure quality. Contraceptive demand is projected to increase dramatically within the MDG time frame as a result of population growth, the current backlog of unad- dressed needs and decreasing family size preferences. The Asia–Pacific region will require the largest share of resources for contraceptives, drugs and medical supplies. But the largest increase – 161 percent – is projected to be in Africa. The Reproductive Health Supplies Coalition has been working to improve information exchange on availability and needs, strengthen supply systems, foster country ownership and national political and financial commitment for reproductive health supplies, improve coordination between international sup- pliers and country supply managers and expand the markets for private-sector provision to appropriate population segments. This effort needs to improve national capacity and to address emergency responses to stock-outs and other supply crises. Allocation of national funds remains an important signal that countries can send that might encourage further donor responses. A coordi- nated effort to increase resources from national and international sources is required, with significant allocations to strengthening national institutions. Executive summary The quality of SRH care leads to greater acceptance of contraceptives and other SRH services and lower rates of discontinuation 17 Such efforts should include improved feedback from local actors (governmen- tal and non-governmental) on evolving demand and on supply quality and dependability. The effective incorporation of SRH commodities into national Essen- tial Drugs and Medicine delivery systems must be realized. Multiple and ill- coordinated logistic management systems reduce efficiency and effectiveness. Existing management tools can provide technical support to such national delivery efforts. Improving access to and usage of family planning services should include programmatic attention to key life events at which demand and receptiv- ity is high. These include services to be offered post-abortion, post-partum, post-infection (by an STI, including HIV/AIDS), post-child death and post- puberty/initiation). Task 5: Meeting the needs of special populations Since the needs of different population groups vary – both in the risks they face and the programs required to reach them – special attention to targeted service development has increased. Sub-groups include such populations as unmar- ried youth, the poor, rural populations, and post-partum and post-abortion women. Adolescents Young women and men are underserved in development planning. Sectoral institutional frameworks tend not to be organized around age categories and do not offer an integrated approach to the needs of the young. Surveys of the health information and service needs, including SRH, of youth show their reluctance to use clinics or to address sex and reproduction. Comprehen- sive and holistic approaches must be developed that are sensitive and youth- friendly. Normative frameworks on client rights are particularly important for reassuring youth. The diversity of situation of adolescent populations must be taken into consideration, with special population groups among adolescents requiring priority attention in program planning. This includes those living in situa- tions of risk and young mothers. Detailed data is needed on the situation of young people, married and unmarried, particularly in the area of SRH. Humanitarian situations A humanitarian crisis – whether it is due to conflict or natural disaster – poses an extreme challenge to the achievement of the MDGs. Structures and systems break down, making people much more vulnerable and increasing the need for protection and service provision. Of the 34 poorest countries that are farthest away from achieving the MDGs, 22 countries are in or just emerging from conflict. Executive summary Young women and men are underserved in development planning 18 The SRH situation during conflict and natural disasters increases the likeli- hood of unwanted pregnancy, maternal and infant death, and the transmission of STIs including HIV/AIDS. The sudden loss of medical support, as well as the trauma and malnutrition that often follow an emergency, means that preg- nant women face a greater risk of maternal morbidity and mortality. The spread of STIs including HIV/AIDS increases because an emergency breaks up stable relationships; disrupts social norms on sexual behavior; and coerces women as well as young girls and boys to exchange sex for food, shelter and income. Gen- der-based violence also increases. Operational guidelines on reproductive health in emergency situations have been developed and must be implemented. Men Men play a crucial role in reproductive health both as clients, partners and agents of change. Donors can support operational research to advance these contribu- tions and countries can give it priority. Gender-equitable programs to involve men should address power relations, and positive and supportive definitions of masculinity should be reinforced to improve the situation of both women and men. Reproductive health strategies should make male involvement a key pro- gram strategy. Outreach to men is a vital component for meaningful scaling up of SRH programs. Program staff will need reorientation to address male involvement. Requirements for effective action Political commitment High-level political commitment can signal the importance of SRH progress to the population as a whole and to implementing bureaucracies. Dramatic change is possible on accelerated time scales when national governments mobilize to meet voluntary choices. Effective coordination To implement the various recommended actions, effective multisectoral pro- gramming efforts are critical. Coordinating mechanisms and institutions can mobilize stakeholders for the design, implementation and monitoring of pro- grams involving diverse actors. Community participation and cultural sensitivity Consistent with this vision is recognition of the vital role of community inputs to development planning. Services can be better adapted to local condi- tions when staff are equipped with methods and guidelines to evaluate their own performance and supplement their evaluations with inputs from service beneficiaries. In order to make reproductive health programs successful, it is crucial to take into account the local context, including structure and culture. Partnering Executive summary To implement the various recommended actions, effective multisectoral programming efforts are critical 19 with local groups such as faith-based organizations and individuals from within the community is therefore a crucial step in a successful program that seeks to promote human rights and healthier lives. Resources for programs Additional information on detailed intervention costs that have become available in the decade since the ICPD have led to new estimates of resource needs for SRH. These estimates include: (a) detailed disaggregated direct ser- vice delivery cost estimates for family planning and other basic maternal and reproductive health services (including safe delivery, emergency obstetric care, neonatal survival/infant mortality interventions and a broad range of HIV/ AIDS prevention efforts); (b) overhead costs (e.g., maintenance, power, basic facility supplies, support staff); and (c) system improvement costs related to management, improved monitoring and evaluation and capacity for research and evaluation needs. Preliminary estimates of additional capital and human resource require- ments for attaining the targeted service coverage are also available. Better esti- mates of these needs will come from ‘bottom-up’ MDG needs assessments carried out by individual countries. UN Millennium Project analyses dem- onstrate that most low-income countries need to substantially increase capital investments to strengthen health systems and scale up service coverage to meet the MDGs. It is clear that resource requirements for the basic SRH pack- age will be significantly higher than estimated over a decade ago. By 2015 the required annual costs will be about US$14 billion more than originally anticipated, reaching US$36 billion. The magnitude and share of required HIV/AIDS prevention investments are substantial. Additional analyses apply this new methodology to a scenario projecting family planning needs, population dynamics and maternal, newborn and child health services based on the satisfaction of current unmet need for family plan- ning. These analyses reflect the larger savings in other reproductive health services gained by higher investments to eliminate unmet need for family plan- ning preferences. Savings from family planning investments increase over time as smaller birth cohorts reduce other service needs and can finance system improvements. Both the 1993 and the current resource projections omit supportive invest- ments in other sectors (including investments for women’s empowerment). The current SRH estimates are also based only on direct service costs and added health system costs and do not include the required information, education and behaviour-change communication and community-based interventions. Further work is needed to elaborate these needs. The expansion of family planning, maternal health and HIV/AIDS pre- vention efforts depends on the mobilization of political will, institutional capacity and technical and financial resources. However, a significant number Executive summary The expansion of family planning, maternal health and HIV/AIDS prevention efforts depends on the mobilization of political will, institutional capacity and technical and financial resources 20 of countries identify shortfalls in international assistance as having a negative effect on their programs. Greatly increased support, both financial and techni- cal, to national programs will be required to reach the ICPD goal of universal access to reproductive health and attain the MDGs. Executive summary At the Millennium Summit in September 2000, 189 world leaders adopted the Millennium Declaration and committed their nations to a global part- nership to reduce poverty, improve health and promote peace, human rights, gender equality and environmental sustainability. This Declaration built on the outcomes of international conferences held throughout the 1990s, recog- nizing the importance of achieving the development goals and targets adopted at previous gatherings. Indeed, it recommitted governments to many of their long-standing promises. Importantly, the Millennium Declaration also explicitly recognized the interconnectedness of development priorities set at these various gatherings – from the International Conference on Population and Development (ICPD) to the Fourth World Conference on Women and to the World Education Forum, among others. World leaders agreed that the many dimensions of extreme pov- erty must be tackled together, and that the aspirations and goals of one confer- ence can only be realized alongside those articulated at the others. To this end, the Millennium Development Goals (MDGs) following from the Millennium Declaration, further held governments to account by setting time-bound and measurable targets for eradicating extreme poverty in its many forms – income poverty, hunger, disease, lack of adequate shelter and exclusion – while promot- ing gender equality, education and environmental sustainability (box 1.1). The World Summit held in September 2005 confirmed the importance of reproductive health in the attainment of the MDGs as countries commit- ted themselves in the Outcome Document to: “Achieving universal access to reproductive health by 2015, as set out at the International Conference on Population and Development, integrating this goal in strategies to attain the internationally agreed development goals, including those contained in the Millennium Declaration, aimed at reducing maternal mortality, improving Introduction S e ctio n 1 22 Sexual and Reproductive Health and the Millennium Development Goals Box 1.1 Millennium Development Goals Goal 1 Eradicate extreme poverty and hunger • Target 1 Halve, between 1990 and 2015, the proportion of people whose income is less than US$1 a day • Target 2 Halve, between 1990 and 2015, the proportion of people who suffer from hunger Goal 2 Achieve universal primary education • Target 3 Ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling Goal 3 Promote gender equality and empower women • Target 4 Eliminate gender disparity in primary and secondary education, preferably by 2005, and to all levels of education no later than 2015 Goal 4 Reduce child mortality • Target 5 Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate Goal 5 Improve maternal health • Target 6 Reduce by three-quarters, between 1990 and 2015, the maternal mortal- ity ratio (MMR) Goal 6 Combat HIV/AIDS, malaria and other diseases • Target 7 Have halted by 2015 and begun to reverse the spread of HIV/AIDS • Target 8 Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases Goal 7 Ensure environmental sustainability • Target 9 Integrate the principles of sustainable development into country policies and programmes and reverse the loss of environmental resources • Target 10 Halve by 2015 the proportion of people without sustainable access to safe drinking water and basic sanitation • Target 11 Have achieved by 2020 a significant improvement in the lives of at least 100 million slum dwellers Goal 8 Develop a global partnership for development • Target 12 Develop further an open, rule-based, predictable, non-discriminatory trading and financial system (includes a commitment to good governance, develop- ment and poverty reduction – both nationally and internationally) • Target 13 Address the special needs of the Least Developed Countries (includes tariff- and quota-free access for Least Developed Countries’ exports, enhanced programme of debt relief for HIPCs and cancellation of official bilateral debt, and more generous ODA for countries committed to poverty reduction) • Target 14 Address the special needs of landlocked countries and small island developing states (through the Programme of Action for the Sustainable Develop- ment of Small Island Developing States and the twenty-second General Assembly provisions) • Target 15 Deal comprehensively with the debt problems of developing countries through national and international measures in order to make debt sustainable in the long term 23Section 1: Introduction maternal health, reducing child mortality, promoting gender equality, combat- ing HIV/AIDS and eradicating poverty” (UN 2005b, paragraph 57g). ICPD and the MDGs – moving forward together Many elements of the Millennium Declaration and the MDGs were anticipated by the broad vision of development elaborated at the ICPD, held in Cairo in 1994. Similar to the Millennium Summit, the ICPD marked the largest inter- national conference of its time, with 179 world leaders adopting its Programme of Action. This set the population and development agenda for the next two decades. The ICPD Programme of Action and the MDGs strongly reinforce each other in a number of important ways. Firstly, the ICPD Programme of Action addressed a myriad of pressing development problems – from eradicating extreme poverty to ensuring environ- mental sustainability to supporting families – and went far beyond what had previously been seen as ‘traditional’ population issues. In fact, early critics of the ICPD Programme of Action worried that the declaration addressed too many varied issues and contained too many targets. But, much like the MDGs, the ICPD Programme of Action explicitly recognized these issues to be fundamen- tally related, and unachievable without action being taken on all of them. For example, without adequate roads, women in labor are not able to access maternal health clinics. And even if they reach a clinic, without adequate electricity they cannot receive the necessary care. The breadth of the development vision thus expanded on the approach in earlier population conferences: “The 1994 Conference was explicitly given a broader mandate on develop- ment issues than previous population conferences, reflecting the growing aware- ness that population, poverty, patterns of production and consumption and the environment are so closely related that none of them can be considered in isola- tion.” (UN 1994, para. 1.5) Secondly, the ICPD Programme of Action set quantifiable targets and indica- tors to measure countries’ progress toward meeting their agreed goals. This was an important step at that time in holding governments accountable for their pledges, and is a shared element of the MDGs. Furthermore, four of the five quantified goals from the ICPD Programme of Action are echoed in the MDGs (see below). Thirdly, the ICPD Programme of Action viewed population concerns from within a human rights framework – creating a key shift in the population debate. • Target 16 In cooperation with developing countries, develop and implement strate- gies for decent and productive work for youth • Target 17 In cooperation with pharmaceutical companies, provide access to afford- able essential drugs in developing countries • Target 18 In cooperation with the private sector, make available the benefits of new technologies, especially information and communication technologies 24 Sexual and Reproductive Health and the Millennium Development Goals It succeeded in replacing a macroeconomic perspective on population policy with a focus on a woman’s need to receive appropriate SRH care (within a func- tioning health system) and to control the number and timing of her pregnancies. The advancement of the human rights perspective on reproductive health, along with a more focused discussion of gender roles in development, was a major step forward. Similarly, the MDGs should be seen as human rights goals – the right to food, shelter, healthcare and education – as enumerated in the Universal Dec- laration of Human Rights and the UN Millennium Declaration. Fourthly, the ICPD Programme of Action explicitly recognized that a true global partnership between rich and poor countries was needed in order to achieve its aspirations. It was the first international conference to accept (how- ever provisionally) estimates of resource requirements for a core program package and to define the relative contributions to these efforts by donor and developing countries. It also explicitly recognized the need for strengthened partnerships on an international, regional and national level. In this same vein, the Millen- nium Declaration and the MDGs explicitly call for strengthened global partner- ships, particularly in such key areas as aid, trade, debt relief, access to essential medicines and foreign direct investment. And the UN Millennium Project also stresses in its recommendations the need for a global partnership between rich and poor countries to achieve the Goals. It is in these ways that the MDGs build on the important outcomes of the ICPD, and they should be viewed as a strong recommitment to the vision, aspi- rations and goals of that landmark event. Four of the five quantifiable targets put forth in the ICPD Programme of Action are included (in close form) in the MDGs – reducing maternal mortality, reducing child mortality and ensur- ing universal access to primary education and access to secondary education (table 1.1). ICPD+5 also included a goal for preventing HIV/AIDS, which is reflected in the MDGs. The fifth ICPD goal – access to SRH services includ- ing family planning – is now widely recognized as essential to the achievement of the MDGs. What is sexual and reproductive health? One of the major innovations of the ICPD was the elaboration of a definition of a rights-based approach to SRH. The concept of SRH and rights adopted at the ICPD marked a turning point in the approach to fertility and fam- ily planning programs. The Programme of Action defined SRH broadly, as encompassing issues related to physical, mental and social well-being in mat- ters related to the reproductive system (box 1.2). At its core is the promotion of healthy, voluntary and safe sexual and reproductive choices for individuals and couples, including such decisions as those on family size and timing of mar- riage. Indeed, such promotion is fundamental to human well-being. Through- out human history, sexuality and reproduction have been vital aspects of per- sonal identity and key to creating fulfilling personal and social relationships. The concept of SRH and rights adopted at the ICPD marked a turning point in the approach to fertility and family planning programs 25Section 1: Introduction SRH also involves issues extending beyond the reproductive years, such as preventing cervical cancer, and emphasizes the need for a life-cycle approach to health.1 Importantly, reproductive health programs involve men as well as women – because men are exposed to sexual risks, men impact the reproductive health of their partners, and men must be involved in programs to eliminate sexual violence and coercion. And SRH touches on sensitive, yet important, issues for individuals, couples and communities, such as sexuality, gender discrimination and male/female power relations. For example, SRH programs work to elimi- nate sex-selective abortions or to eliminate harmful traditional practices, such as female genital cutting (FGC ) or forced early marriage. As the World Health Organization (WHO) Reproductive Health Strategy (2004) affirmed: “Reproductive health extends before and after the years of reproduction, and is closely associated with socio-cultural factors, gender roles and the respect and Box 1.2 ICPD definition of reproductive health “Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when, and how often to do so….Reproductive health care is defined as the constellation of methods, techniques and services that con- tribute to reproductive health and well-being by preventing and solving reproductive health problems. It also includes sexual health, the purpose of which is the enhancement of life and personal relations, and not merely counseling and care related to reproduction and sexually transmitted diseases.” (UN 1994, para. 7.2) ICPD Goals Targets Universal access to primary education “…countries should….strive to ensure complete access to primary school or equivalent level of education by girls and boys as quickly as possible, and in any case before 2015“ (paragraph 11.6) Access to secondary and higher education “Beyond the achievement of the goal of universal primary education in all countries before the year 2015, all countries are urged to ensure the widest and earliest possible access by girls and women to secondary and higher levels of education, as well as to vocational education and technical training“ (paragraph 4.18) Reduction of infant and child mortality “By 2015, all countries should aim to achieve an infant mortality rate be- low 35 per 1,000 live births and an under-five mortality rate below 45 per 1,000. Countries that achieve these levels earlier should strive to lower them further” (paragraph 8.16) Reduction of maternal mortality “Countries should strive to effect significant reductions in maternal mor- tality and morbidity by the year 2015 (.) to levels where they no longer constitute a public health problem. Disparities in maternal mortality within countries and between geographical regions, socio-economic and ethnic groups should be narrowed” (paragraph 8.21) Universal access to re- productive and sexual health services includ- ing family planning “All countries should strive to make accessible through the primary health- care system, reproductive health to all individuals of appropriate ages as soon as possible and no later than the year 2015” (paragraph 7.6) Table 1.1 ICPD quantifiable targets 26 Sexual and Reproductive Health and the Millennium Development Goals protection of human rights, especially – but not only – in regard to sexuality and personal relationships.” Given the broad definition of SRH, a wide range of interventions and program activities are needed for its promotion. Interventions are needed, for example, to ensure access to SRH information and services, to promote gender equality and women’s empowerment and to eliminate gender-based violence and sexual coercion (see Appendix 2 for a list of interventions). Programs, therefore, must involve many different actors – from government officials to community and cultural leaders to civil society and the private sector down to families and individuals (both men and women). Finally, SRH programs are committed to strengthening healthcare delivery in developing countries, and are working to ensure that SRH activities are fully integrated into these systems. Recently, in an attempt to further refine this broad definition as it relates to the health system, WHO (2004a) identified five key interventions that, although not comprehensive, are key to successful SRH programs: 1. Ensuring contraceptive choice and safety 2. Improving maternal and newborn health 3. Reducing sexually transmitted and other reproductive tract infections and HIV/AIDS 4. Eliminating unsafe abortion 5. Promoting healthy sexuality. Reproductive rights SRH goes well beyond simply delivering services and information about disease prevention and risk reduction (although these activities are essential aspects of SRH programming). At its core is the promotion of healthy, voluntary and safe sexual and reproductive choices for individuals and couples, including such deci- sions as those on family size and timing of marriage. The International Conference on Human Rights in Tehran in 1968 was the first international forum to explicitly state that “Parents have a basic human right to determine freely and responsibly the number and spacing of their chil- dren”. And this was reaffirmed at the 1975 First World Conference on Women, which argued that the right to family planning was essential for gender equality. The 1984 International Conference on Population again endorsed this right, and further concluded that men shared responsibility for family planning and child rearing. These references to reproductive rights are not new, but instead bring together long-standing accepted norms from various internationally agreed human rights frameworks that are relevant to SRH. The Universal Declaration of Human Rights (1948) put forth a common standard of achievement for all peoples and all nations that included certain fundamental political, social, economic and cul- tural rights and freedoms. Based on this, the International Covenant on Civil and Political Rights (1976) and the International Covenant on Economic, Social “Parents have a basic human right to determine freely and responsibly the number and spacing of their children” 27Section 1: Introduction and Cultural Rights (1976) both stressed the right of women to be free of all forms of discrimination, the right to the highest attainable standard of physical and mental health as well as family rights (the right to marry and found a family and the right to have a private and family life). Other human rights treaties and conventions set clearer definitions and stan- dards for the protection of women against discrimination and for ensuring their access to SRH services. The Convention on the Elimination of All Forms of Dis- crimination against Women (1979), for example, set out measures for achieving gender equality, including overcoming the disadvantage inherent in gender roles. The Convention on the Rights of the Child (1989) also reaffirmed the right to family planning services. It called on States to ensure appropriate antenatal and post-natal care for mothers, to protect children from sexual violence and coercion and to abolish traditional practices that harm the health of a child. And given that nearly all States have ratified this Convention, it has become a particularly strong tool for holding governments accountable for ensuring universal access to SRH services, including family planning. While these conferences, treaties and conventions include reproductive health as a human right, however, it was the ICPD that fully elaborated the concept of reproductive rights: “Reproductive rights embrace certain human rights that are already recog- nized in national laws, international human rights documents and other con- sensus documents. These 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, and the right to attain the highest standard of sexual and reproductive health. It also includes their right to make decisions concerning reproduction free of dis- crimination, coercion and violence, as expressed in human rights documents….” (UN 1994, para. 7.3) The concept of reproductive rights is important for (at least) three key reasons: 1. Human rights instruments set clear definitions for the basic minimum entitlements that all people the world over should enjoy, no matter who they are or where they were born. All too often, ‘cultural heritage’ and ‘age-old tradition’ arguments have been used to maintain practices that, for example, denigrate women and their contributions to families, com- munities and nations, or that pose great risks to a woman’s health (i.e., FGC). Reproductive rights make clear that certain practices are not to be condoned simply because they are deemed cultural or traditional and that in fact such practices violate internationally agreed norms. 2. Stemming from these rights are obligations on States to ensure that access to SRH information and services is afforded to all persons; to eliminate gender-based violence, sexual coercion and forced early marriage; to ensure high-quality healthcare to reduce maternal and child mortality; and so on. A 2003 United Nations Population Fund (UNFPA) survey Reproductive rights embrace certain human rights that are already recognized in national laws, international human rights documents and other consensus documents 28 Sexual and Reproductive Health and the Millennium Development Goals Reproductive rights, as derived from international human rights instruments, specifically include: • Right to the highest attainable standard of health includes a right to have access to healthcare of the highest possible quality, which includes access to sexual and reproductive health (SRH) services and information. • Right to life and survival mostly focuses on ensuring safeguards against arbitrary execution by the state. But some experts have also applied this right to women who die of pregnancy-related causes and have demanded governments provide services to reduce maternal mortality. • Right to liberty and security of person implies a right to enjoy and control one’s sexual and reproductive life in accord with the rights of others. For example, sexual coercion and abuse as well as FGC violate the security of a person. So too do com- pulsory sterilization and forced abortion. • Right to family planning specifies that individuals have a right to freely and responsi- bly decide the number and spacing of their children and have access to the informa- tion and services to do so. This is a key component of reproductive rights. • Right to marry and found a family specifies that individuals should be able to freely consent to marriage as well as to the number and spacing of their children. Some experts have also applied this right as an obligation for States to provide preven- tion and treatment services for STIs, as these are a leading cause of infertility. • Right to a private life and family life includes the ability to make autonomous and confidential decisions about sexuality and the number and spacing of one’s chil- dren – free from coercion, discrimination and violence. • Right to the benefits of scientific progress implies that everyone should have access to available technology in reproductive healthcare, including quality contraceptive options. • Rights to receive information and to freedom of thought are also applicable to SRH issues in that everyone (including adolescents and unmarried women) must have access to family planning information and services. • Right to education is important in and of itself. But this right also empowers women with knowledge and skills to be able to participate in the life of their communities, and to challenge traditional gender roles. • Right to non-discrimination on the basis of sex is essential for achieving gender equality and, in particular, for women to make choices about their reproductive health without their spouse’s consent. Gender-based discrimination occurs in many regions the world over and is exemplified by the differential treatment of boys and girls as well as by sex-selective abortions. • Right to non-discrimination on the basis of age implies that young people should have the same rights to confidentiality as adults with regard to their reproductive healthcare. Box 1.3 Reproductive rights as human rights found that since the adoption of this language, 131 countries had changed national policies or laws to explicitly recognize reproductive rights. South Africa and Venezuela, for example, include reproductive rights in their constitutions as fundamental human rights (UNFPA 2004b). 29Section 1: Introduction 3. Countries that have ratified these human rights instruments are required to report regularly on actions undertaken to ensure that their citizens enjoy such rights. The established monitoring bodies may also offer rec- ommendations to specific States or groups on actions they should take to implement their agreed human rights responsibilities, and specifi- cally with respect to reproductive rights. For example, national progress related to SRH and rights has been part of the purview of the Commit- tee on the Elimination of Discrimination against Women (CEDAW), and has been included in national reports and shadow reports to the Committee and in its Concluding Comments (see the databases acces- sible at http://www.whrnet.org/docs/issue-cedaw_committee.html and http://www.acpd.ca/compilation/Intro.htm). The Special Rapporteur on the Right to Health has reported on the sta- tus of rights in the area of SRH, within the context of existing norms and concepts such as freedoms, entitlements, immediate obligations, international assistance and cooperation, articulating rights issues emerging from the ICPD, the Fourth World Conference on Women and their review processes (Com- mission on Human Rights 2004). In official Resolutions following from the reports of the Commission on Human Rights, the General Assembly “calls upon States to place a gender perspective at the centre of all policies and programmes affecting women’s health” and “ further calls upon States to protect and promote sexual and reproductive health as integral elements of the right of everyone to the enjoyment of the highest attainable standard of physical and mental health” (ibid.). Reproductive rights are recognized as valuable ends in themselves and essen- tial to the enjoyment of other fundamental rights. Ensuring universal access to SRH and rights is thus an important part of strategies for achieving the MDGs. The achievement of some Goals – including improving maternal health, reduc- ing child mortality, promoting gender equality and combating HIV/AIDS – depend directly on making access to these services widespread. Other Goals are also closely connected with SRH issues, since the ability to make informed deci- sions concerning reproductive health, marriage and childbearing without any form of discrimination or coercion is closely correlated with a country’s prospects of reducing poverty, improving health and education, raising productivity and living standards, and achieving environmental sustainability (UNFPA 2005c). These various connections are considered in detail in Section 3. First, however, Section 2 looks at the current situation as regards SRH. Ensuring universal access to SRH and rights is thus an important part of strategies for achieving the MDGs This section starts by looking at the global burden of diseases and risks related to sexual and reproductive health (SRH). It reviews the extent to which most regions, countries, sub-national areas and populations are ‘falling short’ in the key areas of SRH (given available data) and compares, to the extent possible, today’s snapshot with that of times past. There have been some spectacular improvements in some areas of SRH – witness the declines in fertility levels over the past few decades. But there have also been serious setbacks, most nota- bly the AIDS crisis in sub-Saharan Africa. This discussion highlights the exist- ing disparities in diseases and risks relevant to SRH – both within and between countries – and the groups or regions with particularly adverse outcomes. Despite the centrality of SRH to the attainment of international develop- ment goals, including those in the International Conference on Population and Development (ICPD) Programme of Action and the Millennium Development Goals (MDGs), it has not been adequately translated into action frameworks and monitoring mechanisms at international, regional and national levels. The final part of the section looks at why SRH has been marginalized in the devel- opment dialogue. The global burden of SRH-related diseases and risks The broad concept of SRH, as defined in Section 1, poses great measurement challenges when trying to highlight the burden of SRH-related diseases and risks globally. Firstly, given the broad scope of the definition and various inter- pretations of SRH, it is not always clear how best to measure its contribution to the overall burden of disease. For example, Murray and Lopez (1998) mea- sured these using six different SRH definitions and came out with six diver- gent estimates – varying as much as from 5 to 20 percent of the total global disease burden. The current situation S e ctio n 2 32 Sexual and Reproductive Health and the Millennium Development Goals Secondly, SRH issues cut across traditional measurement lines. SRH includes diseases (e.g., AIDS) and ‘non-diseases’ or normal physiological processes (e.g., pregnancy), as well as including both communicable diseases (e.g., STI) and non-communicable ones (e.g., breast cancer). These disease groups are usually measured and classified separately, making estimating the total SRH burden more difficult. Thirdly, it is important to measure factors that either increase or decrease a person’s risk of exposure to poor SRH outcomes. And such risk factors often relate to lifestyle, culture and behavior. But data on these factors are usually hard to obtain as they touch on intimate topics that are difficult for individu- als or communities to discuss. And often those at the greatest risk of suffering adverse SRH outcomes are the same people who are hardest for such surveys to reach (such as sex workers or adolescents). Fourthly, the measurement of the disease burden does not take into account impacts on families, communities and society, but only reductions in individ- ual functioning. Intergenerational impacts of poor realization of reproductive health are excluded, including those beyond the area of physical impairment. Finally, and fundamentally, good health is much more than the absence of disease. And this becomes abundantly clear with SRH – arguably more so than in other areas of health. Throughout history great emphasis has been placed on sexuality, pregnancy and childbearing. Indeed, much of our personal identity as well as our social and personal relationships hinge on this part of our lives – which is closely related to our overall health and well-being. Today’s measurement tools are not able to capture such positive aspects of health and well-being (see further discussion in Section 3 under Goal 3). Estimates of the overall SRH burden Despite the difficulty of assessing the overall SRH burden, estimates of the extent to which adverse outcomes lead to death and disability have been made. These show that lack of access to SRH is (and has long been) a major public health concern, especially in developing countries. A recent costing study of SRH interventions (Vlassoff et al. 2004) reviewed the burden of disease estimates for components of SRH (table 2.1 and 2.2). According to these estimates, death and disability due to SRH accounted for 18.4 percent of the overall global disease burden and 32 percent of the dis- ease burden among women of reproductive age (15–44). Maternal conditions (including hemorrhage or sepsis due to childbirth, obstructed labor, pregnancy- related hypertensive disorders and unsafe abortion) accounted for 2.1 percent of all disability-adjusted life years (DALYs)2 lost (and 13 percent among women of reproductive age) in 2001. And this disease burden has stayed relatively con- stant over the past decade, decreasing from 2.2 percent in 1990 to 2.1 percent in 2001. Perinatal conditions (including low birth weight, birth asphyxia and birth trauma) accounted for 6.7 percent of all DALYs lost in 2001. HIV/AIDS Good health is much more than the absence of disease 33Section 2: The current situation Years of life lost (YLL) (months) Years lived with disability (YLD) (months) Disability-adjusted life years (DALY) (months) Percent of all DALYs 1990 2001 1990 2001 1990 2001 1990 2001 STIs 6.5 5.4 12.0 7.0 18.5 12.4 1.3 0.9 HIV 8.8 80.0 2.3 8.4 11.2 88.0 0.8 6.0 Maternal conditions 13.3 15.0 16.5 15.9 29.8 30.8 2.2 2.1 Total 28.6 100.4 30.8 31.3 59.5 131.3 4.3 9.0 accounted for 6 percent (and 14 percent among women of reproductive age), up from 0.8 percent in 1990. And STIs, excluding HIV/AIDS, accounted for 0.9 percent of all DALYs lost in 2001, down from 1.3 percent in 1990. Across regions there are great disparities in the total burden of disease due to SRH problems (table 2.2). Nowhere are the disparities clearer than in terms of HIV/AIDS, as 18.8 percent of the total disease burden is due to HIV/AIDS in Africa, compared to 6 percent worldwide and 0.6 percent in Europe. In fact, the disease burden in Africa, due in large part to the HIV/AIDS crisis, is about one third of the total disease burden, and is almost double that of most other regions. Most other SRH problems also account for a larger portion of DALYs lost in Africa than in other regions. In Europe, conversely, the SRH burden is relatively low compared to the region’s overall burden of disease, accounting for only 6.9 percent. Other regions show SRH burdens accounting for 10–20 percent of the total disease burden. Clearly, from these estimates, SRH poses a serious burden in many regions, but especially in Africa, and accounts for a good proportion of the total disease burden in much of the world. Table 2.1 Burden of disease estimates related to reproductive health, 1990 and 2001 Note: Numbers in table may not sum because of rounds. Source: Vlassoff et al. 2004 Table 2.2 Share of DALYs lost due to reproductive health-related causes, by region, 2001 (percent) Note: Numbers in table may not sum because of rounds. Source: Vlassoff et al. 2004 World Africa Americas Europe Eastern Mediter- ranean South- east Asia Western Pacific STIs (excluding HIV/AIDS) 0.8 1.4 0.4 0.2 1.0 1.0 0.2 HIV/AIDS 6.0 18.8 1.9 0.6 1.3 3.2 0.8 Maternal conditions 2.1 3.2 1.3 0.5 3.0 2.4 1.1 Perinatal conditions 6.7 6.1 4.9 1.9 9.1 9.4 5.7 Other SRH conditions 2.7 1.7 3.5 3.7 2.5 2.8 3.0 Total (percent) 18.4 31.3 12.0 6.9 16.9 18.9 10.8 Total DALYs (thousands) 270 112 17 10 23 79 28 34 Sexual and Reproductive Health and the Millennium Development Goals Measuring progress in key areas of SRH Fertility levels Much of the world has seen spectacular declines in fertility levels over the past few decades. In more developed regions, the total fertility rate3 was relatively stable at 1.55 children per woman in 1995–2000 and 1.56 in 2000–2005. Both periods have fertility rates below replacement level.4 In less developed regions, total fertility also declined over the same period – from 3.1 to 2.9 children per woman. However, if China is excluded, this decline was only from 3.64 to 3.35. Northern Africa, in particular, experienced rapid declines in fertility levels, espe- cially in Algeria, Jordan and Libya. And by the late 1990s, total fertility levels fell below five children per woman in most countries of Asia, Latin America and the Caribbean and Oceania. Indeed, by 2000, approximately 44 percent of the world’s population lived in countries with below replacement fertility. In the least developed countries, however, fertility levels are still estimated at 5.02 for 2000–2005 (UN Population Division 2002a and 2005b). In addi- tion, many countries have seen the decline slow down in recent years. India, in particular, saw progress in reducing fertility rates – which dropped from about 5.5 to 4 children per woman during the 1970s and 1980s– slow during the 1990s. Bangladesh saw slowing progress during the 1990s as well, with fertility levels holding steady at about three children per woman during that decade. El Salvador, Haiti, Malaysia, Myanmar, Paraguay and Peru experienced similar slowdowns, with rapid fertility declines during the 1970s and 1980s followed by slower (or no) declines during the 1990s. Even worse, some countries (mostly in Africa) did not experience fertility declines at all over the past few decades, and continue to have rates above five children per woman (table 2.3). In addition, pockets of high fertility within countries continue to exist – with poor and rural populations often having the least access to family planning information and services, and thus the highest fertility rates. In countries with fertility rates above six children per woman, such as in Mali or Nigeria, there is often little difference between income groups within countries. In these countries the total fertility rate does not fall below four children per woman even among the wealthy. In countries with overall lower or intermediate fertility rates, such as some Latin American countries, fertility levels range from 3.5 to 5.1 children per woman. In six Latin American countries, the wealthiest quintile has fertility rates around two children per woman (below replacement levels), while the poorest have rates around five (UNFPA 2002b). High fertility levels are also often found among young married women, espe- cially adolescents (see below). Reasons why fertility rates have not declined in Africa can vary from country to country but there are some overall explanations. Firstly, the region has a very high desired family size compared to other regions. Secondly, only small num- bers of married women have access to and use modern contraceptives. Thirdly, the reduced international support for family planning challenges the needed Poor and rural populations often having the least access to family planning information and services, and thus the highest fertility rates 35Section 2: The current situation investments in these programs. And finally, Africa has many fragile governments and health systems, which imposes further challenges to reaching the poor with public services, including effective contraceptive information and services (Cle- land and Sinding 2005). Table 2.3 suggests that countries with total fertility rates that have remained above five children per woman over the past few decades share similar charac- teristics. Under-five mortality rates were high in these countries in 1995–2000 – ranging between 135 and 287 child deaths per 1,000 live births. Compare this rate to that of less developed regions with an average rate of 95 child deaths per 1,000 live births, or even least developed countries with an under-five mortality rate of 167 per 1,000 live births. Almost all of these countries had less than half of their populations living in urban areas. Table 2.3 Countries where total fertility rate remains above five children per woman and has not decreased since 1960, selected characteristics, late 1990s Source: UN Population Division 2004 Total fertility rate Under-five mortality Percentage urban Gross national income per capita at purchasing power parity (international dollars) Late 1990s 1995–2000 1999 2000 Angola 7.2 218 34 1,230 Burkina Faso 6.8 170 19 1,020 Burundi 6.8 211 9 580 Chad 6.6 212 24 860 Congo 6.3 135 63 590 Democratic Republic of Congo 6.7 151 30 680 Equatorial Guinea 5.9 177 48 4,770 Guinea 5.5 207 33 1,930 Liberia 6.8 172 45 – Malawi 6.3 238 25 600 Mali 7.0 261 30 790 Niger 7.5 228 21 760 Sierra Leone 6.5 287 37 460 Somalia 7.3 204 28 – Uganda 7.1 186 14 1,230 Least developed countries 5.5 167 26 – Less developed regions 3.1 95 40 – Adolescents, early marriage and fertility Many of the MDGs refer to adolescents, of whom one in four is estimated to live in extreme poverty (UNFPA 2005d). There are over one billion ado- lescents between the ages of 10 and 19, accounting for about 20 percent of the world’s total population. More than 85 percent of these young people 36 Sexual and Reproductive Health and the Millennium Development Goals live in the developing world (Bruce and Chong 2006). The total number of adolescents in the world will not change over the coming decades. About 14 million adolescents each year gave birth to a child during the period 1995– 2000. Of these teen mothers, 12.8 million lived in developing countries. Africa experienced the highest proportion of adolescent childbearing in the world, with a fertility rate in 1995–2000 of 122 births per 1,000 women aged 15–19. This was expected to decrease in 2000–2005 to 114 births per 1,000 women (table 2.4). Table 2.4 Age-specific fertility rates for women aged 15–19 by major region, 1995–2005 (per 1,000) Source: UN Population Division 2005c Region 1995–2000 2000–2005 Africa 122 114 Asia 53 46 Europe 24 21 Latin America and the Caribbean 86 80 Northern America 50 48 Oceania 40 32 World 64 59 More developed regions 20 27 Less developed regions 71 64 Least developed countries 136 125 Higher fertility rates among adolescents have been linked to early mar- riage. In most countries, especially developing countries, childbearing takes place in the context of marriage – making age at marriage a primary indica- tor for exposure to risk of pregnancy. Overall, among 20–24-year-olds, 90 percent of young women have their first births after marriage – with varia- tion ranging from 70 percent in Eastern and Southern Africa to 97 percent in Southern Asia to nearly 100 percent in the Arab States (Lloyd 2006). And in developing countries, between half and three quarters of all first births to married women occur within the first two years of marriage (Singh and Samara 1996). Recent findings further suggest that this interval between marriage and first birth (known as the ‘first birth interval’) is decreasing in all regions except in the Asian countries of the former Soviet Union. Among women currently aged 40–44, their first birth interval ranged from 13–26 months. Among the youngest cohort (15–19-year-olds), the range narrowed to 14–21 months (National Research Council and Institute of Medicine 2005). Given these first birth intervals, childbearing between the ages of 15 and 19 on average reflects young women marrying between the ages of 13 and 18. Even though the majority of these births occur in the last two years 37Section 2: The current situation of the age cohort in most settings, the major portion of the adolescent fertil- ity rate would still reflect an age of marriage as early as age 16. Globally, there has been a rise in the average age of marriage, and this has contributed to declines in adolescent fertility. This is particularly the case in Northern Africa, Western Asia and South-central and Southeastern Asia. An analysis conducted by the UN Population Division (Mensch and Singh 2003) suggests that in almost two thirds of the 11 countries that experienced the fastest declines in fertility, less than 10 percent of the women aged 15–19 had ever been married. In Algeria, for example, the mean age at marriage increased by five years between 1980 and 1992 (to after age 25), which was closely associated with a significant decline in fertility levels by more than two children per decade between 1979 and 1995. Despite a rise in the average age at marriage worldwide, however, a sub- stantial proportion of women in developing countries still marry at a young age (Singh and Samara 1996). Indeed, great variation exists in age at mar- riage and early childbearing both between and within countries. In some countries, up to 50 percent of women marry or enter a union by age 18, with this figure rising to 70 percent by age 20. It is difficult to estimate the number of early marriages because many marriages are unregistered and unofficial, and even fewer are officially acknowledged for children under the age of 14. An exception is in Ban- gladesh, where the Demographic and Health Survey (DHS) found that, in 1996–1997, 5 percent of 10–14-year-olds were already married. In the Indian state of Rajasthan, a small survey of 5,000 women conducted in 1993 found that 56 percent were married before the age of 15, and 17 percent of these marriages occurred before age 10. In Nepal 7 percent of girls are married before age 10 and 40 percent by age 15. High rates of early marriage also appear to occur in Afghanistan, Burkina Faso, Cameroon, Mali, Niger and Uganda. A recent UNICEF survey found that 44 percent of women aged 20–24 in Niger got married when they were under the age of 15. Early mar- riage is less common in Northern Africa, the Arab States and Latin America and the Caribbean (UNICEF 2001a). India, Indonesia, Pakistan and Yemen have the highest proportion of women married or in union by age 20, and also have three of the four high- est rates of adolescent fertility in their regions (South-central, Southeastern and Western Asia). Similarly in sub-Saharan Africa, six countries (Burkina Faso, Cameroon, Malawi, Mali, Niger and Uganda) with the highest pro- portion of women married by age 20 also have four of the highest adoles- cent fertility rates. Finally, in Latin America and the Caribbean, the four countries (El Salvador, Guatemala, Nicaragua and Trinidad and Tobago) that have the highest proportions of women married by age 20 also include the three countries with the highest adolescent fertility rates (U.S. Bureau of the Census 1996). Despite a rise in the average age at marriage worldwide, however, a substantial proportion of women in developing countries still marry at a young age 38 Sexual and Reproductive Health and the Millennium Development Goals Family planning These spectacular declines in overall fertility levels have been met with and driven by equally dramatic increases, on average, in the use of family plan- ning services over the past few decades. More than 60 percent of couples in less developed countries use family planning services today, compared with 10 percent in 1960. Moreover, the success of family planning efforts has impacted the number of children a couple reportedly desires. In Kenya, for example, women reported wanting just 3.9 children today on average, com- pared with 7.2 in the 1970s. Despite such advances, about 201 million women who want to space or limit their childbearing are still not using effective modern methods of con- traception: 137 million women are using no method at all and 64 million are using less effective traditional methods (UN Millennium Project 2005b). Such high levels of unmet need for effective contraception has led to about 70 to 80 million unintended pregnancies each year in developing countries. Almost one fifth of married women in developing countries have such unmet need for family planning services. And in Africa, only about a quarter of couples are using family planning services. There are also large disparities both across and within countries in the use of family planning services. For example, while most Africans hardly use family planning services, almost half of married women in some countries – especially in Northern and Southern Africa – are using contraception. This rate is three to five times higher than in many other countries of that region. Western Africa, for example, has very low family planning usage, except in Ghana. In Asia (excluding China) the use of family planning services is similar to levels found in Northern and Southern Africa. With China, this proportion rises even higher to 66 percent. Prevalence of contraceptive use is very low in other countries of that region including Afghanistan, Bhutan, Iraq and Lao PDR – with each of these countries experiencing rates below 20 percent. Countries in Latin America and the Caribbean have relatively high Table 2.5 Average age at marriage and percentage of men and women aged 15–19 and 20–24 who are ever married Source: UN Population Division 2004 Average age at marriage(years) Difference in average age at marriage (years) Percentage ever married in age group 15–19 Percentage ever married in age group 20–24 Region Males Females Males - Females Males Females Males Females World 27.6 24.1 3.3 2.3 13.3 21.2 46.1 Africa 26.8 21.9 5.0 3.3 24.8 24.8 63.1 Asia and Oceania 26.6 23.4 3.2 2.7 13.0 24.9 51.0 Europe and Northern America 28.8 26.1 2.8 0.6 3.6 13.9 30.7 Latin America and the Caribbean 28.5 25.5 2.8 2.7 10.9 19.6 36.2 39Section 2: The current situation contraceptive prevalence rates, at about of 69 percent, and there exists little variation between them. Another important measure of unmet need is the proportion of desires for family planning satisfied. This human rights-based measure of access to family planning addresses the degree to which individuals are able to translate their fertility preferences into action and is a combination of unmet needs for family planning and the contraceptive prevalence rate. Data from DHS from 1996 to 2004 show that Africa on average has the lowest proportion of demand satisfied for all contraceptive methods, with only a 40 percent satisfaction rate, while Central Asia has a satisfaction rate of almost 84 percent (figure 2.1). When data are disaggregated by wealth quintiles a clear picture emerges: The poorer groups in all regions have the smallest proportion of their fertility desires satis- fied while, not surprisingly, the richest have a much higher satisfaction rate – a rate that never goes below 40 percent. The proportion of desires satisfied in the poorest quintile roughly matches the overall contraceptive prevalence Figure 2.1 Proportion of family planning desires satisfied for all contraceptive methods, by wealth quintile, survey periods 1990–1995 and 1996–2004 Notes: The two survey periods are not strictly comparable because they may contain different sets of countries Some countries with two data points in one period had the point close to the boundary year reassigned up or down to capture change over time Regional averages are not weighted by population, but by countries per region Regional averages include only countries in that region with data; other countries have not been included. If more countries were added, it could significantly change the aggregates Wealth quintile average is a simple average, and does not account for differences in wealth quintile groups between countries Source: Data complied from DHS STATcompiler 2005 accessed at www.measuredhs.com Pe rc en ta ge Africa 0 20 40 60 80 100 10 30 50 70 90 A A Pe rc en ta ge 0 20 40 60 80 100 10 30 50 70 90 Latin America and Carribean Central Asia Northern Africa and Western Asia Asia Global average Africa Latin America and Carribean Central Asia Northern Africa and Western Asia Asia Global average Poorest Second Middle Fourth Richest Average 1996–2004 1990–1995 40 Sexual and Reproductive Health and the Millennium Development Goals rate, including countries with very low prevalence. Regional variations are very large: Even the richest in Africa have a lower proportion of their desires satis- fied than the poorest in both Asia and Central Asia. Over time in almost every region the proportion of people who have their desires for family planning satisfied is increasing. The only regions excepted from this development are Northern Africa and Western Asia. Interestingly, the increase in the proportion of desires satisfied appears across all wealth quintiles, indicating that every quintile to some extent is positively affected over time. Adolescents and contraception While contraceptive use among adolescents has been on the rise, this group still has a significantly higher unmet need for modern contraception than the general population in many countries around the world. The proportion of young women who are not using contraception in spite of being exposed to the risk of an unwanted pregnancy ranged between 17 and 47 percent of mar- ried women aged 15–19 in 26 developing countries in the mid-1990s. This range narrowed to between 16 and 40 percent of married women aged 20–24. Data from 94 national surveys taken over the past decade demonstrate that the unmet need of adolescents is 2.3 times higher than that of the general population in these countries. In sub-Saharan Africa, less than 20 percent of sexually active adolescents use contraception. This figure rises to between 20 and 40 percent in Asia and Northern Africa and is consistently over 30 percent in Latin America and the Caribbean, the region with the highest average in the developing world. In this age group, unmet need for family planning is predominantly a desire to delay pregnancy. Addressing these preferences could reduce exposure to reproductive risks and empower young women in educa- tion, employment and social participation. Men5 Men play a crucial part in SRH outcomes, and the more informed men become about living safer sexual and reproductive lives, the better the outcome for their partner and family. Men are involved as advocates for needed services, as sup- porters of their partner’s needs and as recipients of services for their own health and well-being. Family planning programs should therefore also address men and their SRH needs. While male sexual and reproductive behavior varies widely across the developing world and among social and ethnic groups within a single coun- try, some broadly similar patterns across regions do emerge. In almost all of 39 developing countries for which recent information is available, the major- ity of men aged 20–24 report having had sexual intercourse before their 20th birthday. A substantial proportion had had sex before their 15th birthday. Among unmarried men aged 15–24 who have ever had sex, two to six in ten Men play a crucial part in SRH outcomes, and the more informed men become about living safer sexual and reproductive lives, the better the outcome for their partner and family 41Section 2: The current situation had two or more partners in the past year. Men in general are more likely to begin sex before marriage than women (INFO 2004). Despite these high levels of youthful sexual activity, fewer than half of sexually active men aged 15–24 in most sub-Saharan African countries use a contraceptive method or rely on their partner’s method, compared to about two thirds in parts of Latin America and the Caribbean. Among men in their late 20s and 30s, contraceptive prevalence is lower in sub-Saharan Africa than in other regions. Reasons for not intending to use contraception are reflected in these men’s desire for more children, which is often higher than women’s; their wives’ reduced risk of pregnancy, e.g., due to infertility; or opposition to family planning itself for religious or other reasons, such as concern about side effects (INFO 2004). In developing countries where men aged 40–54 report moderate or high levels of contraceptive use, meth- ods used by women (especially female sterilization) predominate. Vasectomy is not commonly performed in most developing countries, except China. A large fraction of married men aged 25–39, particularly in sub-Saharan Africa, report that they have not discussed family planning with their partners. Data show that communication between husband and wife about family planning and desired number of children is closely linked to successful contraceptive use. However, the same data also show that more men are likely to approve contraceptive use than women think, and that 90 percent of men in 36 of the 46 surveyed countries knew about either one or more traditional and modern contraceptive methods (INFO 2004). Failure to communicate, linked to tra- ditional sex roles, impedes family planning acceptance. Differing regional levels of risk of unintended pregnancy can be clearly seen in the fact that some 20–46 percent of men aged 25–54 in sub-Saharan Africa and 15–30 percent of those in Latin America and the Caribbean do not want a child soon, or do not want any more children, but are not pro- tected against unplanned pregnancy. Men’s reported number of sexual partners varies considerably by coun- try. In most countries, a majority of all men aged 25–39 had had only one sexual partner in the past year, in most cases their spouse. Yet 7–36 percent of married men had had one or more extramarital partners, and some 15–65 percent of unmarried men in this age group – who represent only a small proportion – had also had more than one partner within that time period. Similarly, some 4–23 percent of married men aged 40–54 had one or more extramarital partners in a recent 12-month period. The use of condoms is higher among unmarried than married men in many cases in Africa because condom use within marriage is associated with unfaithfulness and mistrust of spouse (INFO 2004). Strikingly few men in their teens or early 20s have become fathers, but half of them have done so by their mid-to-late 20s. Men become parents later in life than women usually because men marry later than women (ibid). Communication between husband and wife about family planning and desired number of children is closely linked to successful contraceptive use 42 Sexual and Reproductive Health and the Millennium Development Goals Maternal and child health As will be described in the following sections of this report (specifically, in the discussion of Goal 5 in Section 3) maternal health must go beyond simply mea- suring the number of maternal deaths averted. It must also include measure- ments of other aspects of maternal health, notably the promotion of healthy, voluntary and safe sexual, reproductive and childbearing choices. This includes having access to key aspects of SRH, such as family planning, including safe and effective contraceptive choices; prevention, treatment and care of STIs and HIV/ AIDS; and access to care before, during and after childbirth. Since discussions of trends in these key aspects of SRH are included in Section 3, the following will focus on the burden of maternal mortality and morbidity worldwide. Maternal mortality and morbidity In no other area of health is the disparity between developed and developing countries as great as it is within maternal health. Women in the developing world face a risk of death during pregnancy that is many times higher than women in industrialized countries. A woman has a 1 in 2,800 lifetime chance that she will die from pregnancy-related complications in industrialized countries, while the corresponding risk in developing countries is 1 in every 61. The lifetime risk is even greater in sub-Saharan Africa – 1 in every 16 – reflecting both higher pregnancy rates and the greater risk associated with each pregnancy (UNICEF, WHO and UNFPA 2004). Maternal mortality is notoriously difficult to measure due to weak civil reg- istration systems in developing countries as well as the size of the population needed for estimating maternal deaths from household surveys (given the rarity of the event and thus the need to measure it per 100,000 live births). Maternal mortality estimates also suffer from severe misclassification and underreport- ing. In recent years, WHO and the United Nations Children’s Fund (UNICEF) (with assistance from UNFPA) have worked to revise these estimates for under- reporting and misclassification, as well as to generate estimates for countries without data. It is estimated that maternal mortality takes some 529,000 lives per year (table 2.6), the majority divided almost equally between Africa with 251,000 and Asia with 253,000. Worldwide, the maternal mortality ratio (MMR) is esti- mated to be about 400 deaths per 100,000 live births. Sub-Saharan Africa has the highest rate at 920 deaths per 100,000 live births followed by South-central Asia with 335 deaths per 100,000 live births. Maternal deaths occur from both direct and indirect complications. Direct complications, which account for 80 percent of maternal deaths, include hemor- rhage, sepsis, hypertensive disorders from pregnancy and abortion complications as well as obstructed labor. Indirect complications, such as malaria and AIDS, account for the remaining maternal deaths. The causes of indirect complications vary from region to region. It has been estimated that for every woman who dies in pregnancy or childbirth approximately 30 more suffer injuries, infection and disabilities 43Section 2: The current situation The toll of disabilities and illness from maternal complications is signifi- cantly higher than the death rate, most dramatically for young women. It has been estimated that for every woman who dies in pregnancy or childbirth approximately 30 more suffer injuries, infection and disabilities. This means that at least 15 million women a year incur this type of damage. The cumu- lative total of those affected by maternal morbidity has been estimated at 300 million, or more than a quarter of adult women in the developing world (UNICEF 2003). Unsafe abortions It is estimated that approximately 27 million legal abortions and another 19 million illegal and unsafe abortions were performed worldwide in 2000. Unsafe abortions lead to about 68,000 maternal deaths each year and hundreds of thousands of disabilities, which disproportionately affect women in developing countries (WHO 2004b) (table 2.7). Thus, one in eight maternal deaths, on average, is due to an abortion-related complication. This is also the average in Africa, while in Asia it increases to one in six and increases again to one in five in Latin America and the Caribbean. The risk of death from an unsafe abor- tion is highest in Africa, where the case fatality rate is about seven deaths per 1,000 unsafe abortions. This rate falls to one in 1,000 in Latin America and the Caribbean and to 0.5 in 1,000 in Europe. Section 3 presents more informa- tion on this issue. Region Maternal mortality ratio (maternal deaths per 100,000 live births) Number of maternal deaths Lifetime risk of maternal death 1 in: World total 400 529,000 74 Developed regionsa 20 2,500 2,800 Europe 24 1,700 2,400 Developing regions 440 527,000 61 Africa 830 251,000 20 Northern Africab 130 4,600 210 Sub-Saharan Africa 920 247,000 16 Asia 330 253,000 94 Eastern Asia 55 11,000 840 South-central Asia 520 207,000 46 South-eastern Asia 210 25,000 140 Western Asia 190 9,800 120 Latin America and the Caribbean 190 22,000 160 Oceania 240 530,000 83 Table 2.6 Estimates of maternal mortality ratios, maternal deaths and lifetime risk for 2000 Notes: a. Includes, in addition to Europe, Australia, Canada, Japan, New Zealand and United States of America, which are excluded from regional totals b. Excludes Sudan, which is included in sub-Saharan Africa Source: UNICEF, WHO and UNFPA 2004 44 Sexual and Reproductive Health and the Millennium Development Goals Region Number of maternal deaths due to unsafe abortion % of all maternal deaths Africa 29,800 12 Asia 34,000 13 Latin America and the Caribbean 3,700 20 Europe 300 17 Table 2.7 Maternal deaths due to unsafe abortion Source: WHO 2004b Access to adequate medical care and skilled birth attendants A major underlying cause of maternal death is poor access to adequate medi- cal care during pregnancy and childbirth. Fifteen percent of pregnant women, even under the best of circumstances, will experience a serious complication that requires medical attention. Most of these complications are treatable if appropriate medical care is accessed. Yet, only 53 percent of women world- wide have access to a midwife or doctor during their childbirth, and only 40 percent of women in developing countries give birth in a hospital or other health facility. From 1990 to 2003, the percentage of births assisted by a skilled atten- dant rose globally from 41 to 57 percent. Indeed, most parts of the world have seen great increases in this area: from 27 to 38 percent in Southern Asia; from 45 to 76 percent in Eastern Asia and the Pacific; and from 74 to 86 percent in Latin America and the Caribbean. However, sub-Saharan Africa with the highest MMR has only had a slight increase from 40 percent to 41 percent (table 2.8). Table 2.8 Trends in percentage of births attended by skilled birth personnel in 58 countries, 1990–2003a Notes: a. Data from Demographic and Health Surveys (DHS), multiple indicator cluster surveys (MICS) and comparable surveys, weighted by the number of births b. Data for deliveries in institutions, not in the home Source: UNICEF’s Childinfo 2005 Region Births covered by the data for the suevey period (%) Births attended by skilled personnel (%) Change 1990–2003 (%)1990 2003 Sub-Saharan Africa 61 40 41 3 Southern Asia 97 27 38 42 Eastern Asia and Pacific 80 45 76 68 Latin America and Caribbeanb 70 74 86 16 Total 75 41 57 38 HIV/AIDS and other STIs HIV/AIDS The HIV/AIDS pandemic is devastating families, communities and societies worldwide – currently taking 3.1 million lives per year while infecting nearly 5 million more. It is estimated that around 40.3 million people are infected with 45Section 2: The current situation HIV, 25.8 million of whom reside in sub-Saharan Africa (UNAIDS 2005a). Few, if any, countries remain untouched by the epidemic, while some have been devastated by its toll – especially those in sub-Saharan Africa. Countries’ expe- riences with AIDS have become increasingly divergent, with prevalence rates among adults in different countries ranging from a fraction of a percent to well over 30 percent. The virus is spreading through different populations at different rates. In sub-Saharan Africa and parts of the Caribbean, the epidemic is clearly established in the general population and is largely spread through heterosexual contact. In the Russian Federation, Eastern Europe and parts of Asia, injection- drug users are at highest risk of exposure, while in other regions transmission is largely due to men having sex with men or to commercial sex work. But no matter the epidemiological pattern, it is almost always the poor and marginalized that are at highest risk of exposure. Additionally, while experience in HIV prevention has grown and deepened over the past decade, recent DHS show that many people worldwide lack practi- cal knowledge on how to prevent HIV infection. While most people had heard of HIV/AIDS, more than half the women and men in most countries worldwide lacked comprehensive and correct knowledge on how to prevent HIV infection. In Benin, for example, only 27 percent of men and 35 percent of women fully know how to prevent HIV. Similarly, only one in three men and fewer than one in four women in Mali comprehensively know how to protect themselves (table 2.9). The proportion of men aged 15–54 who know that condom use is a way of preventing HIV/AIDS varies widely in developing countries – from 9 percent in Bangladesh to 82 percent in Brazil (Greene et al. 2006). Respondents who have heard of HIV/AIDS (%) Respondents who have knowledge of HIV prevention methods (%)b Countries Male Female Male Female Benin 98 96 27 35 Burkina Faso 96 96 37 14 Cameroon 99 98 66 54 Ghana 99 98 70 62 Kenya 99 99 67 55 Malawi 100 99 55 49 Mali 98 90 31 23 Mozambique 98 96 52 35 Nigeria 97 86 47 32 Rwanda 100 100 62 48 Unied Republic of Tanzania 100 99 63 58 Table 2.9 Knowledge of HIV/AIDS, men and women, in selected sub-Sharan African countriesa Notes: a. The surveys were undertaken between 2000 and 2004 b. The percentage of respondents who, in response to a prompted question, say that people can protect themselves from contracting HIV by having no penetrative sex, using condoms or having sex only with one faithful, uninfected partner Source: Data compiled from DHS HIV/AIDS Survey Indicators Database 2005 46 Sexual and Reproductive Health and the Millennium Development Goals Sexually transmitted infections6 The prevalence of curable and incurable STIs (including HIV/AIDS) is higher in sub-Saharan Africa and in Latin America and the Caribbean than in other regions. STIs are an important co-factor that increases the risk of HIV/AIDS infection. The estimated annual prevalence of curable STIs per 1,000 people among men and women aged 15–49 ranges from almost 119 infections in sub-Saharan Africa to 71 in Latin America and the Caribbean, to 50 in Southern and Southeastern Asia and 21 in Northern Africa and the Arab States. And of the 40.3 million adults and children living with HIV/ AIDS in the world, 25.8 million live in sub-Saharan Africa, 7.4 million in Southern and Southeastern Asia and 2.1 million in Latin America and the Caribbean (UNAIDS 2005a). In some parts of the developing world, men may be prepared to use con- doms but are unable to obtain them, especially young men and those with lim- ited resources or living in rural areas. When sexually experienced sub-Saharan African men aged 15–24 were asked if they knew where to obtain condoms, only half or fewer of those in rural areas of Chad, Guinea, Mali, Mozambique and Niger knew of a source. Today, an estimated 6–9 billion condoms are dis- tributed each year for family planning and for STI prevention, but many more – approximately 19–24 billion a year – are needed to protect populations from unplanned pregnancies, HIV and other STIs. Gender-based violence Gender-based violence is a significant public health problem that affects mil- lions of women worldwide. It is often considered to be a private matter and therefore many women do not report the violent incidents. Gender-based vio- lence against women is practiced both by partners and non-partners, but inti- mate partner violence (IPV) is the most common form of violence in women’s lives. Between a quarter to half of women have been victims of sexual violence by an intimate partner (WHO 2005c). Among adolescent girls this figure jumps to more than one in three (WHO 2002). A recent study undertaken by WHO among 24,000 women in 10 coun- tries7 found that abused women were more than twice as likely as non-abused to have poor health, including reproductive health, and both physical and mental problems. These women also had increased risk of contracting an STI, including HIV/AIDS. Among pregnant abused women, 4–12 percent reported being beaten during pregnancy, including being kicked and punched in the abdomen (WHO 2005c). Though inequities and certain social norms per- petuate abuse, partner violence appears to have a similar impact on women regardless of where they live, or their economic and cultural background. Due to the impact of gender-based violence on women’s lives and rights, violence- prevention programming must be integrated into programs and policies that aim at children, youth, HIV/AIDS and SRH. Abused women were more than twice as likely as non- abused to have poor health 47Section 2: The current situation Why hasn’t SRH been given higher priority? Disparate elements, multiple owners, multiple discourses One of the reasons why SRH is not a priority issue is the complexity of the concept itself. All health outcomes are complexly determined by social factors, economic factors and health system responses. But SRH issues are more intri- cately implicated in social dynamics, power relationships and individual deci- sions. SRH is also comprised of disparate elements including safe motherhood, family planning, child health, harmful traditional practices, women’s empow- erment, gender-based violence, etc. Its breadth requires multidimensional and multisectoral action in health, education, information, statistical and women’s ministries. Without clear ‘sectoral ownership’ it is hard for decision makers and implementers to take up the burden of a coordinated response. Moreover, since the components of SRH fall under the province of dif- ferent national actors (and international donors), the separation of functions has led to competition rather than synergies. In a similar fashion, the SRH agenda has suffered from its checkered allocation to diverse MDGs (i.e., safe motherhood to Goal 5, child mortality to Goal 4, gender equality to Goal 3, HIV/AIDS to Goal 6) and from the exclusion of family planning. Lacking an integrated understanding of the SRH concept, governments have tended to lower its priority in poverty-reduction discussions. Part of the difficulty also is that there are multiple discourses regarding SRH. A public health framework emphasizes risks and costs. A rights frame- work emphasizes freedoms, guarantees and mechanisms. A moral framework gives higher priority to responsibilities and proscriptions. An instrumentalist framework seeks demonstrated – often quantified – consequences and attri- butions of causality. A less stringent discourse about linkages and relations explores correlations without examination of mechanisms. An institutional framework emphasizes goal-directed processes and pragmatic organization. Further, varying cultural definitions compete in multicultural settings. Yet, the groups advancing differing concerns have difficulty engaging in constructive dialogue about this important area of human experience. Human rights arguments for increasing access to reproductive health may be advo- cated by rights advocates but are not taken to be determinative. Instrumental- ists worry about the proliferation of rights claims and claimants and do not admit the arguments as evidence for decisions. Institutional analysts may grasp the complexities of social action and actors, but often cannot motivate action rather than analysis, particularly when a complex set of diverse institutions are directing outcomes. Worse, different constituencies advance the different perspectives. Rights perspectives are championed by civil society organizations. Instrumentalist perspectives are the chosen discourse of decision makers addressing fiscal con- straints. Institutional analyses are the province of academics. There are often few opportunities for these groups to directly engage each other. Lacking an integrated understanding of the SRH concept, governments have tended to lower its priority in poverty- reduction discussions 48 Sexual and Reproductive Health and the Millennium Development Goals Decisions arise out of a complex political process that unfolds over time. National strategy definition and operational planning takes place within orga- nizations and processes that exclude key actors and their differing perspectives. NGOs are infrequently given full partnership roles in national policy discus- sions. These tensions are particularly relevant when the topic under consider- ation involves sex, reproduction and gender relations. In many countries, various cultural groups have different understandings and positions on these matters (and on associated service provision). This further reduces discussion and atten- tion so political divisions can be avoided. This political hesitancy is reinforced when there is stigma associated with public discussion. Reproductive health has become a fit topic for international discussion and consensus only within the last 10–15 years. Diverse time scales The targeted time frame for the MDGs also helps direct attention away from some elements of the SRH agenda. Changes in attitudes and behavior generally unfold over extended periods of time. It is no surprise, then, that the targets and indicators chosen for the gender equality goal are ones that are measurable, where countries have the capacity, in the short term. These include increased female enrollment rates in education, gender balance in enrollment ratios, wom- en’s participation in the non-agricultural labor force, and women’s representation in parliaments. Clearly, population dynamics and fertility and mortality transitions develop over long periods of time as well. However, even within the short time horizon of the MDGs dramatic impacts can be seen on the size of infant, child and school- age entrant population cohorts as a result of both mortality reduction and fertil- ity reduction. The largest impacts on overall population structures result from variations in observed fertility. Moreover, the extended time frame of change in demographic behavior and in gender relations does not mean that they will not contribute immediately to prog- ress and development. To the contrary, progress in gender equality and in access to reproductive health will catalyze additional changes and contribute to virtuous circles of accelerating progress that will foster development beyond 2015. Lack of sufficient attention to women’s situations and rights The first MDG target – elimination of gender disparities in primary and sec- ondary education – which was to be achieved by 2005 has not been met. The MDG lagging most in attainment is Goal 5: Improve Maternal Health. Mater- nal mortality has not declined in the highest mortality groups. The commitment of political actors to address gender equality concerns needs more convincing demonstration. As noted above, the targets and indicators chosen for the gender equality goal are those that are measurable within the MDG time frame. Important Progress in gender equality and in access to reproductive health will catalyze additional changes and contribute to virtuous circles of accelerating progress that will foster development beyond 2015 49Section 2: The current situation and more subtle issues regarding the dynamics of gender inequality were not included in the MDG framework. These have been highlighted by the UN Millennium Project Task Force on Education and Gender Equality (2005d), which has made a list of proposed indicators to track progress on their strategic priorities for Goal 3 (see table 2.10). Priority-setting mechanisms Some methods that inform decision-making on investments in health are biased against SRH8. Investments in preventive health measures are fre- quently accorded lower priority than curative investments because of the classes of actors involved (e.g., medically trained personnel without public health sensitivity). In many areas of health people’s exposure to risks and their ability to avoid them is given less concern than the treatment response of the health system.9 A disease-oriented (rather than health-oriented) discourse and a con- centration on evaluation and allocation methods (e.g., DALYs) focused on disease conditions helps undermine support for preventive interventions, for multisectoral strategies and for health promotion. Pregnancy is not a disease (unless there are complications and/or interactions with other diseases) and children are a natural and expected part of relationships. That the timing and spacing of children (and eventual limitation of family size) is a health deci- sion and that access to relevant information and services could be a health system priority is not as obvious. The analytic tools offered to developing countries do not sufficiently value SRH interventions like family planning. (For a longer discussion, see AbouZahr and Vaughn 2000.) Many national planners learned development economics before the recent analytical advances on the effect of age structures on poverty reduction (see Section 3, Goal 1). Returns on investments are difficult to calibrate when different categories of investment in different sectors are relevant and when returns are diverse and non-monetized. Health risks avoided, opportunities seized and the like may be easier to capture than direct returns realized. It is easier to quantify the effects of failing to invest in SRH than to specify the gains from investments. However, this does not fit into a decision-making frame related to the marginal impact of specified new investments. Victim of its own success – forecasts and projections The increases in contraceptive use, and corresponding declines in fertility, attained over the past several decades have been a significant contribution of family planning and reproductive health programs (see above.) The United Nations Population Division’s estimates and projections of global, regional and national populations (UNDESA 2001, 2004, 2005) have decreased projections of global population size in some revisions (with small increases less noted in public discussion). Additional analyses indicate that a growing It is easier to quantify the effects of failing to invest in SRH than to specify the gains from investments 50 Sexual and Reproductive Health and the Millennium Development Goals S ev en s tr at eg ic p rio rit ie s fo r w om en ’s em po w er m en t de ve lo pe d by t he U N M ill en ni um P ro je ct T as k Fo rc e on E du ca ti on a nd G en de r Eq ua lit y M D G w om en ’s e m po w er m en t m ea su re s A dd it io na l w om en ’s e m po w er m en t in di ca to rs re co m m en de d by t he U N M ill en ni um P ro je ct Ta sk F or ce o n Ed uc at io n an d G en de r Eq ua lit y Ta rg et s In di ca to rs 1 . S tr en gt he n op po rt un it ie s fo r po st pr im ar y ed uc at io n fo r gi rls w hi le s im ul ta ne ou sl y m ee tin g co m m it m en ts t o un iv er sa l p ri m ar y ed uc at io n Ta rg et 4 : El im in at e ge nd er d is pa ri ty in p ri - m ar y an d se co nd ar y ed uc at io n, p re fe ra bl y by 2 0 0 5 , an d in a ll le ve ls o f ed uc at io n no la te r th an 2 0 1 5 9. R at io o f gi rls t o bo ys in p ri m ar y, s ec on d- ar y an d te rt ia ry e du ca tio n 10 . R at io o f lit er at e w om en t o m en , 1 5 –2 4 ye ar s ol d • Th e ra tio o f fe m al e to m al e gr os s en ro llm en t ra te s in p ri m ar y, s ec on da ry a nd t er tia ry ed uc at io n • Th e ra tio o f fe m al e to m al e co m pl et io n ra te s in p ri m ar y, s ec on da ry a nd t er tia ry e du ca tio n 2 . G ua ra nt ee s ex ua l a nd r ep ro du ct iv e he al th an d ri gh ts Ta rg et 6 : R ed uc e by t hr ee q ua rt er s, be tw ee n 1 9 9 0 a nd 2 0 1 5 , th e m at er na l m or ta lit y ra tio Ta rg et 7 : H av e ha lte d by 2 0 1 5 a nd b eg un to r ev er se t he s pr ea d of H IV /A ID S 16 . M at er na l m or ta lit y ra tio 17 . Pr op or tio n of b ir th s at te nd ed b y sk ill ed he al th p er so nn el 1 8 . H IV p re va le nc e am on g pr eg na nt w om en ag ed 1 5 –2 5 y ea rs 1 9. C on do m u se r at e of t he c on tr ac ep ti ve pr ev al en ce r at e • Pr op or tio n of c on tr ac ep ti ve d em an d sa tis - fie d • Ad ol es ce nt f er til it y ra te 3 . In ve st in in fr as tr uc tu re t o re du ce w om en ’s an d gi rls ’ tim e bu rd en N o su ff ic ie nt t ar ge t N o su ff ic ie nt in di ca to r • H ou rs p er d ay ( or y ea r) w om en a nd m en sp en d fe tc hi ng w at er a nd c ol le ct in g fu el 4 . G ua ra nt ee w om en ’s a nd g irl s’ p ro pe rt y an d in he ri ta nc e ri gh ts N o su ff ic ie nt t ar ge t N o su ff ic ie nt in di ca to r • La nd o w ne rs hi p by m al e, f em al e or jo in tl y he ld • H ou si ng t it le , di sa gg re ga te d by m al e, f em al e or jo in tl y he ld 5 . El im in at e ge nd er in eq ua lit y in e m pl oy m en t by d ec re as in g w om en ’s r el ia nc e on in fo rm al em pl oy m en t, c lo si ng g en de r ga ps in e ar ni ng s an d re du ci ng o cc up at io na l s eg re ga tio n Ta rg et 4 : El im in at e ge nd er d is pa ri ty in p ri - m ar y an d se co nd ar y ed uc at io n, p re fe ra bl y by 2 0 0 5 , an d in a ll le ve ls o f ed uc at io n no la te r th an 2 0 1 5 Ta rg et 1 6 : In c oo pe ra tio n w it h de ve lo p - in g co un tr ie s, d ev el op a nd im pl em en t st ra te gi es f or d ec en t an d pr od uc ti ve w or k fo r yo ut h 1 1 . S ha re o f w om en in w ag e em pl oy m en t in th e no n- ag ri cu ltu ra l s ec to r 4 5 . U ne m pl oy m en t ra te o f yo un g pe op le ag ed 1 5 –2 4 , ea ch s ex a nd t ot al • S ha re o f w om en in e m pl oy m en t, b ot h w ag e an d se lf- em pl oy m en t, b y ty pe • G en de r ga ps in e ar ni ng s in w ag e an d se lf- em pl oy m en t 6 . In cr ea se w om en ’s s ha re o f se at s in n at io na l pa rli am en ts a nd lo ca l g ov er nm en ta l b od ie s Ta rg et 4 : El im in at e ge nd er d is pa ri ty in p ri - m ar y an d se co nd ar y ed uc at io n, p re fe ra bl y by 2 0 0 5 , an d in a ll le ve ls o f ed uc at io n no la te r th an 2 0 1 5 1 2 . Pr op or tio n of s ea ts h el d by w om en in na tio na l p ar lia m en t • Pe rc en ta ge o f se at s he ld b y w om en in na tio na l p ar lia m en t • Pe rc en ta ge o f se at s he ld b y w om en in lo ca l go ve rn m en t bo di es 7. C om ba t vi ol en ce a ga in st g irl s an d w om en N o su ff ic ie nt t ar ge t N o su ff ic ie nt in di ca to r • Pr ev al en ce o f do m es ti c vi ol en ceTa bl e 2 .1 0 S tr e ng th e n in g th e M D G f ra m ew o rk t o m e a su re w o m e n’ s e m p ow e rm e nt S ou rc e: U N M ill en ni um P ro je ct 2 0 0 5 d 51Section 2: The current situation number of countries have reached or gone below replacement fertility levels, presaging population decline and accelerated population ageing. As the number (and size) of countries with persistently high fertility declined, a new discourse challenging the high fertility/high population growth rationale for program attention was developed and championed by opponents of the SRH agenda. In this view, the success of population pro- grams meant that they were no longer relevant to the emerging development paradigm of the 21st century (Wattenberg 1997; Eberstadt 2002). This record has led some to consider lower family size preferences and realized fertility levels as inevitable, not requiring special attention or invest- ment. However, this fails to recognize that national experience shows many examples of delayed or stalled fertility declines and suggests that projections are often optimistic about the pace of fertility decline once near-replace- ment levels are attained (Bongaarts 2002; Bongaarts 2005; Casterline and Roushdy 2005). Moreover, projections are not forecasts. They are the results implied from specified assumptions. Most projections use assumptions pred- icated on continuation of past progress in expanding access to SRH services, including family planning. Donor countries face different demographic situations. Some are expe- riencing or facing national population declines. Because population aging is most pronounced in the more developed countries of Europe and Japan, where persistent low fertility has become the norm, the view that reduced priority should be given to population growth issues has resonated with the domestic concerns of donor communities. As often occurs (sometimes benev- olently and sometimes with unintended negative consequences), the develop- ing countries became pawns of an internal donor dialogue. The race against population growth was, in effect, declared over before everyone crossed the finish line. Governments also tend to reify population projections. Investments in reproductive health capacity-building and service delivery are often omit- ted from development plans, even as projections of incremental declines in population growth are presented in the situation descriptions. The changing institutional architecture The shift away from project support to a program approach in development assistance – appropriately justified to increase efficiency and ownership – was the start of a process that continues to reduce the ability of donors to ear- mark funds for particular services. Recently, several major donors for health system development (including the UK’s DFID and the World Bank) have increased their level of assistance provided as direct budget support, reducing their ability to speak up for too-often neglected areas of women’s health. At the same time, though, vertical pipelines exist for some interventions (e.g., HIV/AIDS) to the detriment of overall health system capacity-building. Investments in reproductive health capacity- building and service delivery are often omitted from development plans 52 Sexual and Reproductive Health and the Millennium Development Goals Within developing countries themselves, health sector reform increasingly incorporates decentralized priority setting. This has provided a mechanism for national authorities to shift their responsibility. Yet such processes should nei- ther absolve governments from setting guidelines for lower level choices nor excuse them from providing vital central support mechanisms – like function- ing logistic systems needed to supply programs with high quality essential drugs, commodities and service practices.10 Sensitivities Matters related to life and death, relationships and pleasure will always arouse strong emotions. The morality-driven politicization of many of the behav- iors and desires associated with sex and reproduction polarizes discussion and promotes a judgmental rather than an outcome-oriented public health approach. Aspects of SRH not reflected in the existing MDG monitoring frame- work also address some hot-button issues. The topic of abortion, for exam- ple, despite the carefully crafted ICPD compromise, mobilizes debate and resistance. Even measuring the reduction of unsafe abortion, or abortions in general, as an indicator of progress in SRH access would often be a political impossibility. Gender relations and adolescents’ needs for information and services add further controversy. Even family planning, some 50 years after the first establishment of programs in developing countries, remains prob- lematic for decision makers responding to concerns in some cultural com- munities, despite the increase in contraceptive use in countries representing all major cultural traditions. The position on abortion adopted by the international consensus at the ICPD has long remained a lightning rod that galvanized opponents of the SRH agenda while invigorating NGOs to press for implementation and the expansion of the consensus. The result of additional negotiations at the 1999 review of the Programme of Action (ICPD+5) was the retention of the Cairo understanding (that induced abortion not be promoted as a method of family planning, that its legal status be determined by national sovereign decisions, and that it be made safe where not prohibited by law), with the elaboration and extension that where the procedure is legal it should be accessible and supported by investments to ensure availability. This sensible compromise only further angered opponents of abortion in particular and of reproductive health and rights programs in general. With the political backing of several important countries, the issue was raised repeatedly during the processes of both the 10th year regional reviews of ICPD in 2004 and the World Summit in 2005. Adolescent SRH is another topic that raises political concerns for gov- ernments. Information and education efforts about sex and reproduction directed to the young can mobilize opposition.11 The international consensus The morality- driven politicization of many of the behaviors and desires associated with sex and reproduction polarizes discussion and promotes a judgmental rather than an outcome- oriented public health approach 53Section 2: The current situation understandings recognize the need for a balance between the rights and responsibilities of parents and the needs and increasing capacity and matu- rity of the young (UN 1994). Different groups understandably view the point of ‘balance’ differently. Many governments are reluctant to address the public health dimensions of age of sexual initiation or acknowledge the sexual activity of young and unmarried people. Harmful traditional practices – including FGC, low women’s status, early marriage and gender-based violence – involve issues of cultural identity and change and the definition of the public and private sphere of behavior and policy concern. Many countries are addressing these issues in national legislation, but others are reluctant. Donor constraints can complicate national discussion and SRH imple- mentation. The United States, a major donor, has strict rules forbidding the provision of development assistance funding for population and reproduc- tive health to developing country institutions that perform abortions (even when permitted by law), provide information about abortion providers, lobby to change national abortion laws, disseminate information about the legal status of abortions or partner with organizations that undertake these actions. In 2005 this set of restrictions was extended to include potential recipients of funding for HIV/AIDS prevention, treatment and care. (It also requires that a set percentage of HIV/AIDS funding be provided to faith- based organizations.) This poses a challenge to national health institutions that wish to receive donor support while implementing national policies and programs or revising them consistent with their own priorities, val- ues and cultural traditions. Given the large amounts of money involved, both in supporting family planning/reproductive health and in HIV/AIDS funding, both positive aspects of the donor’s actions, such restrictions are implicitly coercive. At the same time, donor contributions can facilitate inclusion of SRH concerns in national discussions. The United States, for example, high- lighted the importance of family planning, and greatly increased funding for contraceptives, in its discussions with the Government of Ethiopia. Various donors have also been influential in raising the priority of ado- lescent health, gender equality, harmful traditional practices, trafficking in women and gender-based violence. Such concerns are often advanced by NGOs within countries, but the availability of donor support provides further legitimacy and resources. The strange case of HIV/AIDS In the MDG framework, reinforced by the proliferation of bilateral and multi- lateral vertical funding mechanisms, HIV/AIDS has been classified with com- municable diseases. In this framework it is not explicitly recognized as a disease largely propagated through sexual contact. Donor constraints can complicate national discussion and SRH implementation 54 Sexual and Reproductive Health and the Millennium Development Goals The separation of the HIV/AIDS community and the reproductive health community has deep historical roots. The family planning movement (the source of the reproductive health initiative) was reluctant to address STIs. It saw services for these as primarily directed to men and worried about stigma being re-attached to its growing legitimacy. That the HIV/AIDS pandemic was, in its earliest years, misunderstood as a disease only of men who had sex with men contributed to this hesitancy. The HIV/AIDS com- munity was more aware of the broader population impact and potential for the transmission of the disease and resented its exclusion from the donor aid f lows directed to population, including condom provision. Now the tables are turned in priority, resource availability and potential for stigma. The trend of resource allocations over the last decade has shown differ- ing concern with different aspects of SRH. Significant advances have been made in mobilizing resources for addressing the HIV/AIDS pandemic. Even so, a high proportion of these allocations have been devoted to treat- ment and care rather than prevention, the core HIV/AIDS issue addressed in the ICPD Programme of Action (UNFPA, UNAIDS and NIDI 2005; Population Action International 2004; UN 2005d). Increases in other reproductive health funding have been more modest, and targeted invest- ment in family planning programs has declined (as discussed in Section 3 under Goal 8). Movements of international attention for funding priority are in part affected by the tyranny of the new. The family planning movement’s ini- tial rise resulted from both the analysis of the impacts of rapid population growth in donor and national communities and from the development of new and effective methods of contraception, initially oral pills and later injectables, implants, female condoms, etc. Expansion of family planning services involves the extension of a largely established set of methods12 to populations not previously reached and to new entrants to the reproductive years and efforts to improve the quality of care. The development of antiretroviral medications to treat HIV/AIDS offers the prospect of changing a deadly disease into a chronic one and benefits from its relative novelty. Maintaining necessary levels of attention and investment is a recurring problem for providers and maturing technolo- gies. The rationale for voluntary family planning to address the impact of high population growth in least developed countries remains valid. But the panache of a new technology is gone. The magnitude of the HIV/AIDS pandemic and the depth of its impact on development have appropriately attracted policy attention and funding. High-level policy statements emphasize the need for better linkages between HIV/AIDS and reproductive health intervention efforts (UNFPA 2004f; UNFPA and UNAIDS 2004). As operational models improve, this focus could increase the momentum for comprehensive integrated programming. The separation of the HIV/AIDS community and the reproductive health community has deep historical roots 55Section 2: The current situation The selection of prevention as a major thematic focus for World AIDS Day in 2005 may signal an important turning point. The Millennium Project Task Force on HIV/AIDS recommended renewed attention to prevention (UN Mil- lennium Project 2005i). An important policy document has now outlined a UN system-wide strategy for addressing HIV prevention that emphasizes SRH concerns (UNAIDS 2005c). As will be discussed in the next section, improving SRH and guaranteeing rights related to sex and reproduction can have immediate impacts on the pros- pects and requirements for progress on the MDGs. This is due to the linkages explored earlier in this report, the catalyzing effect of participatory mecha- nisms and responsive public systems and the savings in public expenditure that can be effected from appropriate investments. Because of its particular sensitivities, progress in national efforts to address SRH can serve as a signal of overall improvement in health systems in general and in the development of accountability and responsiveness to an active citizenry. Progress in national efforts to address SRH can serve as a signal of overall improvement in health systems in general Ensuring universal access to sexual and reproductive health (SRH) is important in and of itself. Indeed, the promotion of healthy, voluntary and safe sexual and reproductive choices for individuals and couples, including such decisions as those on family size and timing of marriage, is essential for human well-being. Throughout human history, sexuality and reproduction have been fundamental aspects of personal identity and key to creating fulfilling personal and social rela- tionships. SRH is also a human right, as elaborated in numerous international human rights instruments, including the Convention on the Rights of the Child (see Section 1). Moreover, ensuring universal access to SRH and rights is also instrumen- tally important for achieving the Milennium Development Goals (MDGs). The achievement of many Goals – including improving maternal health, promoting gender equality and combating HIV/AIDS – depends directly on making access to SRH services widespread. Other Goals, such as reduc- ing extreme poverty and attaining environmental sustainability, share a less direct – but no less certain – relationship with SRH. This section explores the evidence that links SRH to the achievement of each of the MDGs. The discussions will describe both the magnitude of the link between SRH and each Goal, as well as the various pathways – both direct and indirect – through which ensuring universal access to SRH and rights acts to affect their achievement. Access to SRH and to other health services have their greatest impact on fertility and mortality, shaping the longer-term course of population dynamics. In addition to affecting individual Goals, evolving population trends define the magnitude of and shape the response needed to accelerate development. S e ctio n 3 The impact of ensuring universal access to SRH and rights on achieving each of the MDGs 58 Sexual and Reproductive Health and the Millennium Development Goals A contextual issue: population dynamics and progress on the MDGs The achievement of the MDGs is influenced by such population dynamics as growth, fertility and mortality levels, age structure and rural–urban distri- bution. Each developing country has its own unique combination of demo- graphic factors, and the prospects for progress toward the MDGs are affected by these dynamics. The achievement of the MDGs is put in jeopardy by high population growth. The pace of this growth differs among regions, with the developed regions having an annual growth rate of 0.3 percent while the less developed regions have a growth rate that is almost five times as fast at 1.4 percent. The least developed countries have an annual growth rate of 2.4 percent, creating an even bigger challenge in these countries (UN Population Division 2005b). Because of these high growth rates the population of the less developed regions is expected to rise from 5.3 billion today to 7.8 billion by 2050 (median vari- ant). The largest population growth will happen in 50 of the least developed countries, and it is estimated that the least developed countries as a whole will double their population size. The high population growth in the less developed regions is due to fertil- ity rates higher than the replacement level. Between 2000 and 2005, the least developed countries had an average fertility rate of 5.02 children per woman while the rest of the less developed countries had a fertility rate of 2.58 children per woman. Of the 35 less developed countries that had a fertility rate of more than five children per woman in that time period, 30 belonged to the group of least developed countries (UN Population Division 2005b). The prospect of achieving economic development is connected to the pos- sibility of increasing productivity and investments in areas such as education, nutrition and health. Population momentum joined with declining fertility rates provides a unique chance to spur economic development as the work force increases and the dependency burden of society decreases. This economic possibility, however, is contingent on policies that create jobs for the grow- ing work force. On the other hand, a society with a high dependency burden spends more of its output on consumption than on investments in education, nutrition or health, with negative consequences for development. A change in the dependency burden means that more resources are available to invest in the human capital of the population. Declining fertility levels as well as a chang- ing age structure are thus important elements of the possibility for investing in development. Young people between the ages of 10 and 24 account for 28 percent of the world’s total population, a majority of them living in developing countries. Compared to the more developed countries, where 20 percent of the popula- tion is between 10 and 24, this age group makes up 29 percent of the total population in the less developed countries (UNFPA 2005d). High fertility The achievement of the MDGs is put in jeopardy by high population growth 59Section 3: The impact of ensuring universal access to SRH and rights on achieving each of the MDGs levels lead to large cohorts between the ages of 0 and 9. The resulting young age dependency burden in the least developed countries and regions creates expanding demand for resources to and investments in education, nutrition and health just to keep pace with population growth. Projected declines in birth rates, should adequate resources help realize them, will allow greater investment in quality improvements as coverage demands moderate. The working-age population (between the ages of 15 and 60) is expected to rise in the least developed countries over the next 50 years from 53 percent in 2000 to 61 percent in 2050, but it will fall marginally in the less developed countries as a whole from 61 percent in 2000 to 59 percent in 2050 (UN Popu- lation Division 2005b). Until the HIV/AIDS epidemic, mortality levels were expected to continue to decline in all regions. The epidemic has reversed this tendency in countries where HIV/AIDS is most prevalent, especially in sub-Saharan Africa (UN Population Division 2005a). From a societal perspective, when people die early investments made are wasted and future productivity is lost. Life expectancy at birth is lower in the developing regions than in the more developed regions, but it is estimated to increase in both less and least developing countries (UN Population Division 2005b). However, the challenge remains in the countries severely affected by HIV/AIDS – the estimated increase in life expectancy is dependent on successful implementation of HIV/AIDS prevention and treat- ment programs. Efforts must be made to ensure that the ‘age bulge’ is not hol- lowed out by the epidemic’s advance. Migration, both internal and international, also conditions the pros- pect for progress towards the MDGs. It is an economic and social strategy complexly affected by both push and pull factors, and this report will not address this demographic process apart from a couple of brief comments. The distribution, density and relocation of populations have implications for public service delivery systems and for the development of market responses to basic needs. The emigration of trained medical personnel is undercut- ting health systems in sub-Saharan Africa, compounding the high mortal- ity risks (including from HIV/AIDS). Recent research is starting to address the implications of migration for development processes in general and the attainment of the MDGs in particular (International Organisation for Migration 2004). Goal 1: Eradicating extreme poverty and hunger Eradicating extreme poverty The relation of population dynamics in general and reproductive health specif- ically to poverty has been a topic of intense debate for much of the last 40 years. Population trends affect the course and prospects for poverty reduction. And the diverse and changing population dynamics have had dramatic impacts in selected regions of the world. The emigration of trained medical personnel is undercutting health systems in sub-Saharan Africa, compounding the high mortality risks (including from HIV/AIDS) 60 Sexual and Reproductive Health and the Millennium Development Goals Sub-Saharan Africa remains in a poverty trap in which demographic fac- tors – high fertility, high infant and child mortality and excess adult mortality (including that due to HIV/AIDS) – play significant roles (UN Millennium Project 2005a). This region has seen the least change in these outcome mea- sures and still lags behind other major sub-regions, despite improvement over the past two decades on process measures of the strength of family planning and reproductive health programs (Ross et al. 2005). Eastern Asia13 has seen dramatic declines in the number of persons living in income poverty, while high levels of poverty persist in some parts of South- ern Asia (at 31 percent). There have been significant gains in China, Indone- sia, Thailand and Viet Nam (fully half of the world’s global decline in those estimated to be living in poverty has occurred in China). The region shows some of the most striking examples of what is now called ‘the demographic bonus’. In fact, when first observed, and before it was appreciated as a general phenomenon, it was named ‘the East Asian miracle’. Recent analyses suggest that somewhere between 25 and 40 percent of macroeconomic growth is attributable to demographic change (Birdsall et al. 2001). This is split roughly evenly between the effects due to decreased mor- tality (health affects productivity) and those due to declining fertility (allow- ing a deepening of human capital investment). At the societal level there is a remarkable one-time opportunity when the proportion of the population of labor force age (15–60) is large relative to the more ‘dependent’14 younger and older populations. This demographic bonus, though, is not guaranteed. It is an opportunity and a challenge that depends on the right priorities, poli- cies and strategies. Population dynamics also have an impact on the national incidence of poverty and inequality. A study of 45 countries estimated that the average poverty incidence would have fallen by one third if the crude birth rate had fallen by five per 1,000 in the 1980s (Eastwood and Lipton 2001). The effect of declining fertility in Brazil has been equal to economic growth of 0.7 per- cent of GDP per capita each year (Paes de Barros et al. 2001). Cleland and Sinding (2005) stress the influence of fertility on economic development and the need for careful analysis in priority setting. Based on evidence showing that one third of Eastern Asia’s economic development is attributable to the short- and long-term effects of fertility decline, they argue that high fertility rates and population growth will have a higher effect on the demographic composition and macroeconomic prospects in most of Africa than HIV/AIDS. This is because the HIV/AIDS pandemic is either on the decline or will not be as widespread as in the countries of Southern Africa. The short- and long-term effects of fertility decline as in East Asia could contribute greatly to economic development. At the household level, smaller families can reduce the depth of pov- erty and increase per child investments in the future, provided there are also Somewhere between 25 and 40 percent of macroeconomic growth is attributable to demographic change 61Section 3: The impact of ensuring universal access to SRH and rights on achieving each of the MDGs supportive policy frameworks at the level of government. Together, these societal and household transformations offer the opportunity for rapid social and economic development if investments are made in health, education and the quality of life, and attention is given to addressing disparities in the dis- tribution of these benefits. In Asia, such attention has often been paid. Many countries have, for example, attained relative parity in girls’ and boys’ access to education at the primary level, and growing attention is being given to ensuring equal and higher access to secondary education as well (UN Mil- lennium Project 2005h). Of course, reaping the rewards of the demographic bonus depends on the wider social and economic context pointed to in other UN Millennium Project documents (UN Millennium Project 2005a). Among the conditions that need to be met are the development of stable governance, accountability mecha- nisms (that allow feedback into policy of the impacts of decisions), conducive trade policies, greater transparency in decision-making and greater opportuni- ties for women. Such improvements in governance are important, but they are not enough to meet the Goals. Countries also need to increase public invest- ments in health, education, basic infrastructure, agriculture and environmen- tal management. Since many of the poorest countries are too poor to afford these investments that are vital for economic growth, they are stuck in poverty that can only be ended if increased aid is made available. When institutions exist that permit the accelerated flow of informa- tion throughout a society (mass media, civil society organizations, social networks), it is possible to have wide dissemination of information of the benefits of smaller families, accurate feedback of the returns to investments in children (hastening the quantity–quality tradeoff) (Montgomery et al. 1999) and quicker recognition of the increased chances of children surviv- ing. Together with an appreciation of the higher support levels given later by children who have received human capital investments, this reduces old-age support motivations for persistent high fertility. The experience of countries that had relatively early and/or rapid fertility transitions demonstrates that such institutional mechanisms can be highly facilitative – e.g., village family planning groups in Indonesia (Shiffman 2004); microcredit groups in Ban- gladesh (Levine et al. 2004). In the absence of information-disseminating networks or campaigns, the poor are less likely than their wealthier compatriots to recognize the signals that facilitate fertility decline, including the benefits from investments in children’s schooling, increased opportunities for women, changes in child survival prospects, legal changes and operational improvements affecting the health system and reproductive health delivery (Greene and Merrick 2005). However, the largest difference between rich and poor families is not in their desired or ideal family sizes but in their ability to implement their preferences. Access to services for the poor can be adversely affected by clinic placement, The largest difference between rich and poor families is not in their desired or ideal family sizes but in their ability to implement their preferences 62 Sexual and Reproductive Health and the Millennium Development Goals hours of service and user fees (UN Millennium Project 2005b). Health clinic personnel may also provide better services to less impoverished clients.16 It will be a long time before the demographic window opens for the poor- est countries, but work towards it now will safeguard the future. It will also protect the present. Pregnancy and childbirth are serious risks for poor women. Many, and unwanted, children impose a heavy burden on them. High levels of fertility contribute directly to poverty, reducing women’s opportunities, dilut- ing expenditure on children’s education and health, precluding savings and increasing vulnerability and insecurity. Eradicating hunger The Millennium Summit roadmap identified the reduction of global hunger and malnutrition as priority development targets. Reproductive health pro- grams can help improve the nutritional status of women and their children and advance progress on the hunger and maternal and child health targets. Nutritional deficits have a profound effect on productivity and health (UN Millennium Project 2005g). Nutritional requirements for women of reproduc- tive age increase during pregnancy. Supplemental feeding programs for preg- nant women, improving women’s knowledge of the nutritional requirements of themselves and their children and increasing women’s power to negotiate access to needed nutrition must be part of a multi-intervention strategy. Closely spaced pregnancies place women at increased risk of anemia and other conditions of absolute and relative malnutrition (WHO 2005b). This can lead to developmental challenges for children, including those risks associ- ated with low birth weights. (Important findings are referenced in Goal 4 on child mortality.) Progress in alleviating hunger also requires targeted inputs to improve agri- cultural productivity. Community level cooperative action can ensure imple- mentation of soil improvement, better water management and other compo- nents of an integrated approach to agricultural productivity. The full set of interventions needed to reduce hunger is described in the report of the UN Millennium Project’s Task Force on Hunger (2005g). However, rapid population growth fueled by high fertility desires and/or poor implementation of preferred family sizes can lead to the sub-division of land holding (e.g., through successive shrinking of plots included in inheri- tances). Decreasing sizes of family plots can change the individual calculus of cost and benefits in various productivity-enhancing interventions (Popula- tion Action International 2003). At the same time, though, population pres- sure can provide incentives for technology shifts. These Boserupian effects (Boserup 1987), however, do not mitigate environmental constraints and require carefully chosen interventions. In local experiments where population pressure, assisted by other facilitating conditions, contributed to significant technological adaptations (e.g., the Machakos district in Kenya17) the danger Pregnancy and childbirth are serious risks for poor women 63Section 3: The impact of ensuring universal access to SRH and rights on achieving each of the MDGs of soil degradation remained significant without appropriate compensatory interventions. Another reproductive health challenge to agricultural produc- tivity and progress on the hunger target arises from the impact of the HIV/ AIDS pandemic on the rural workforce in highly affected countries. Goal 2: Achieve universal primary education While Goal 2 focuses on achieving only universal primary education, this sec- tion will discuss the impact of SRH, including family planning, on achieving universal access to all levels of education, not just primary. The discussion of Goal 3, then, will focus on how access to SRH is essential for achieving gender equality more broadly. Discussing the impact of SRH on access to educational opportunities (without separating the discussion by level of education) has many advantages. Firstly, it is useful to describe the impact of SRH on a sector broadly (such as for education or environment), as policy at the national level is often shaped in this way. Secondly, and importantly, SRH affects various levels of education in similar and overlapping ways. For example, girls may be taken out of school to care for siblings at any time during their education. Pregnancy-related drop- outs, too, may occur at any level of education, including the primary level. Conventional wisdom suggests that fertility levels, including parental and adolescent fertility, have an impact on both children’s access to schooling and their educational attainment. Girls in small families are less likely to drop out of school due to pregnancy, or to be pulled out due to the costs of school- ing or the indirect costs of foregone household labor if a child attends school. As family size increases, however, such costs increase – making it more likely for children to be taken out of school. At the societal level, declining fertil- ity levels may increase the available schooling opportunities for children, as competition for such population-level resources declines. Evidence does exist to bear out these theories to an extent, although the relationships are often quite complex. Family size linked to educational attainment, especially for girls At the household level, conventional wisdom suggests that as families grow larger, parents can less afford to send each child to school due to the direct costs of schooling. Children’s contributions to the household are also foregone when they attend school, and often such contributions are needed simply for the family to survive. This is especially true of girls, whose traditional role is to care for younger siblings and help with household chores. Thus, there is a strong incentive for larger families to keep children, especially girls, at home and out of school. In countries where the state is relatively weak and has lim- ited enforcement powers, families often have greater control over children’s access to public resources, such as schooling, which makes it is difficult for children to access education without their parents’ consent. Declining fertility levels may increase the available schooling opportunities for children 64 Sexual and Reproductive Health and the Millennium Development Goals Most empirical studies on educational attainment in countries where family size has been on the decline have found that a child’s school attainment is nega- tively associated with the number of siblings with whom the child lives (National Research Council and Institute of Medicine 2005). Throughout the 1990s this relationship was investigated in a number of developing countries, and

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