Report of the International Forum for the Operational Review and Appraisal of the Implementation of the Programme of Action of the International Conference on Population and Development (ICPD)

62. At the International Conference on Population and Development, countries endorsed the principle that all couples and individuals should be enabled to make voluntary reproductive choices free of coercion. Ensuring that couples and individuals have the ability to carry out these choices was recognized as a basic right.

63. Reproductive health, including family planning and sexual health, encompasses the full range of components pertaining to the reproductive and sexual health of women and men, throughout the life cycle. The reproductive health approach not only requires an expansion of the components of service provision, but recognizes women as subjects rather than objects; upholds their dignity; respects their free and informed choices; and responds in a comprehensive manner to the totality of their health needs.

64. Since 1994, there has been a noticeable momentum in policy and programme development in reproductive rights and health, with significant progress in the understanding of a human rights-based approach to reproductive health, including family planning and sexual health; in moving away from vertical service provision, demographic targets and quotas; and in promoting adolescent reproductive health.

1. Many countries have developed specific policies and/or legislative or institutional changes in reproductive health and rights.

2. Some countries have adopted a participatory approach involving stakeholders in identifying priorities and making choices about available services.

3. Many countries are experimenting with the integration of reproductive health services into their health delivery systems; some progress has occurred in reproductive health services at the primary health care level, and in the establishment of referral systems.

4. Reproductive health is increasingly considered a priority in health services in emergency situations.

5. The provision of high-quality, client-responsive services ensuring free and informed choice has received increased attention.

6. Some countries have taken measures to address the health needs, especially the sexual and reproductive health needs, of adolescents. NGOs have been involved in providing life-skills training in making choices and decisions; building self-esteem and addressing sexuality and gender equality. Efforts have been made to promote education for girls.

7. It is recognized that work with men and particularly with boys is essential. Some concrete measures have been taken to broaden and promote male involvement in sexual and reproductive health through advocacy campaigns.

8. There has been some progress in providing universal access to a full range of safe and reliable family planning methods. A wider range of contraceptive choices has become available, including the female condom and emergency contraception. Some countries are moving away from an emphasis on one or two contraceptive methods.

9. There is greater awareness of the risks of maternal mortality and morbidity, and recognition at the international level that maternal mortality and morbidity is both a developmental and a human rights issue.

10. A growing number of countries have acknowledged unsafe abortion as a serious public health concern. A few countries have advanced in establishing services where abortion is legal.

11. Evidence is showing that efforts to prevent STDs including HIV/AIDS through behavioural change and condom distribution and social marketing are cost-effective and becoming more effective. Where strong national programmes have been initiated, the rate of HIV infection has begun to decline especially among younger age groups, and among army conscripts and commercial sex workers.

65. Although there is general support and increasing understanding of reproductive rights as described in the ICPD Programme of Action, policies do not yet consistently reflect human rights approaches nor is there always sufficient political commitment for developing and implementing such policies. In many countries, existing laws and regulations also impede the implementation of the ICPD Programme of Action in specific areas such as sexuality education and the access of adolescents to reproductive health information and services.

66. At present, 54 countries have entered reservations to various articles of the Convention on the Elimination of all forms of Discrimination Against Women (CEDAW).

67. In the development of reproductive health programmes, insufficient understanding of how best to implement the reproductive health approach among some policymakers and health professionals remains a constraint to the implementation of the Programme of Action.

68. The advent of health sector reform and sector-wide approaches requires measures to safeguard reproductive health as a high priority. Decentralization of programme implementation has also placed an increased responsibility on programme managers.

69. Reproductive health policies and programmes have also tended to be shaped primarily by the health sector to the exclusion of other sectors which have an important role to play in this area.

70. Improving the quality of reproductive health care is often seen as too costly. Many studies reveal, however, that existing resources are often under-utilized, and improvements can be made at reasonable costs. Standards of quality have not always been developed and applied. Lack of service providers trained in all aspects of reproductive health care also represents a constraint.

71. Lack of information and increasing unprotected sexual relations place adolescent girls and boys at risk of STDs, including HIV/AIDS, and young girls at risk of unwanted pregnancy. Early pregnancies constitute an increased risk of mortality and morbidity, including unsafe abortion, to the young girl, and also greatly limit her life opportunities in many countries. Harmful traditional practices, such as FGM and early marriage, or family formation (as described in paragraph 5.1 of the Programme of Action) also puts girls at increased risk.

72. The rights of all individuals in refugee or emergency situations require protection. In addition, the reproductive health care needs of such persons, especially women and adolescents, continue to exist and are exacerbated by increased sexual violence and lack of services.

73. Although some advances have been made on initiatives concerning male involvement and responsibility in sexual and reproductive health, overall progress on male responsibility and on services for men has been limited.

74. Family planning services have expanded over the last five years. More than 150 million women however, still lack access to family planning information and services because of logistical, social, cultural, financial and behavioural barriers.

75. Women in developing countries and countries with economies in transition continue to face an unacceptable and far greater risk of severe complications or death in pregnancy and childbirth than women living in developed countries. Approximately 600,000 women, the vast majority in developing countries, die each year from the complications of pregnancy and delivery. Furthermore, for every woman who dies, many more suffer severe injury, malnutrition or ill health.

76. Unsafe abortion, as defined in the Programme of Action, remains a major public health concern and a major cause of maternal mortality. It is estimated that some 20 million unsafe abortions occur each year, and that as many as 80,000 women die as a result. Recourse to abortion results from a lack of information and access to safe and effective contraceptives; this is particularly the case for young women.

77. At least 330 million new cases of curable sexually-transmitted diseases occur each year, and the global epidemic of HIV/AIDS continues unchallenged in all but a few countries. More than 33 million people were living with HIV/AIDS in 1998, and millions of persons every day face the risk of HIV transmission; the effects of HIV infection; or the impact of the epidemic on some aspect of their lives. Half of all new HIV infections are in young persons aged 15-24.

78. Most countries have begun to operationalize reproductive health programmes to some extent. As a result, a wealth of experience is beginning to be built; this experience needs to be shared by countries in order to accelerate the current pace of progress.

79. Some of the actions proposed in the area of reproductive rights include:

1. Legislation and policies should be enacted and implemented to meet the commitments made at Cairo that ensure reproductive rights, gender equity and equality, including voluntary choice in marriage, family forms - as described in para 5.1 of the Programme of Action - and the determination of the number, spacing and timing of children.

2. Health systems in collaboration with all other appropriate sectors need to ensure that policies, strategic plans, and all aspects of reproductive health programme implementation are based on human rights, and cover the life cycle.

3. The knowledge base and confidence of women, men and adolescents should be strengthened to enable them to claim reproductive rights and promote their reproductive health, including effective use of health services.

4. The human rights of women include their right to have control over and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence.

5. Governments should withdraw reservations to Article 16 of the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW). To ensure universal implementation of the Convention, reservations to all other articles should also be withdrawn.

6. The United Nations system should develop methodologies and indicators to promote and monitor women's rights, in particular in the area of sexual and reproductive health.

80. Governments should:

1. Maintain high priority for sexual and reproductive health, and ensure equity of access to information and services when implementing health sector reform and sector-wide approaches.

2. Facilitate participatory policy development processes to include representatives of all stakeholders, and donors should coordinate their support with the resulting national agendas.

3. Engage not only the health sector but all relevant sectors in reproductive health policy development and implementation.

4. Promote the decentralization of health planning and implementation in order to better identify and respond to the reproductive health needs of people, including psycho-social issues, cervical and breast cancer and reproductive tract infections.

5. Establish long-term strategic partnerships with all civil society partners, including NGOs, to strengthen the planning and implementation of reproductive programmes.

6. Strengthen the integration of services where this will result in increased acceptability, utilization and cost-effectiveness.

7. Increase investments in standards of service provision, maximizing the use of existing resources to provide quality services, with continuing monitoring.

8. Increase investments in reproductive health training to provide technical skills and prepare providers to communicate clearly with empathy, confidentiality and with respect for human rights, gender equality and dignity, and to provide dignified care.

9. Develop selected indicators, both quantitative and qualitative, to monitor progress in achieving the goals agreed at ICPD, including indicators for measuring gender sensitivity in sexual and reproductive health.

10. Strengthen community-based services and social and subsidized marketing, which are vital extensions of primary health care services; and explore new partnerships with the private sector.

11. Allocate resources to meet the growing demand for access to information, counselling, services and follow-up on the full range of safe and effective contraceptive methods, including the female condom and emergency contraception. Logistics systems should ensure the continuing availability of high-quality family planning and reproductive health commodities at delivery points.

12. Recognize and promote safe motherhood as a human rights issue.

13. Train and deploy increased numbers of primary health care workers with life-saving skills, develop effective referral systems including transportation to the secondary level of care and ensure that skilled workers are available to provide quality services, particularly emergency obstetric care.

14. Establish intermediate benchmarks for 2005, 2010 and 2015 for maternal mortality, such as the proportion of deliveries attended by a skilled attendant.

15. Promote men's understanding of their roles and responsibilities in promoting women's health and preventing unwanted pregnancy, maternal mortality, and transmission of sexually-transmitted diseases, including HIV/AIDS.

16. Recognize and address unsafe abortion as a public health problem.

17. Reduce unsafe abortions by diminishing the number of unwanted pregnancies through the provision of family planning information and services, including emergency contraception, and by investing in the training and equipping of medical service personnel to manage the complications of unsafe abortions. Where it is legal, abortion should be safe and accessible. Laws containing punitive measures against women who have undergone illegal abortions should be reviewed.

18. Reaffirm commitment to Paragraph 8.25 of the Programme of Action and develop a system for monitoring its implementation.

81. Governments should:

1. Commit the highest political levels to taking urgent action to control HIV/AIDS epidemics; to prevent HIV transmission; to improve care for HIV-infected persons; and to take steps to mitigate the impact of the AIDS epidemic.

2. Provide necessary resources to UNAIDS Co-sponsors and Secretariat to enable them to carry out their mandates in providing policy, strategic and technical guidance and support to countries in combating the HIV/AIDS pandemic.

3. Ensure that prevention of HIV/AIDS becomes an integral part of reproductive health programmes, particularly at the primary health care level.

4. Ensure access to available technologies such as female and male condoms.

5. Invest in the development of STD prevention and treatment programmes.

6. Ensure that communication campaigns include sexuality and gender-power issues.

7. Ensure that men should not threaten women's human rights through practices and behaviour that put women directly at risk from STDs, including HIV/AIDS, particularly by inflicting sexual violence on girls and women.

8. Develop goals and benchmarks to monitor progress in preventing HIV/AIDS.

9. Develop modules on HIV/AIDS to be included in the sex education curricula for all adolescents.

10. Create an environment free of discrimination for people and ensure access and availability of the required drugs for HIV-infected persons in developing countries.

11. Promote and fund research on microbicides, simpler diagnostic tests, single-dose treatments for STDs, and vaccines.

82. Some of the actions proposed in the area of adolescent reproductive health include:

1. Sexual and reproductive health programmes for adolescents should encompass not only sex education and provision of contraceptives but also basic health care, STD prevention and treatment, effective referral services, and counseling that addresses sexuality, builds self-esteem, promotes gender equality, and ensures privacy and confidentiality.

2. Innovative strategies need to be developed that provide adolescent girls and boys with sexual and reproductive health information through both formal and informal education - including peer counselling - that promotes gender equality and responsible sexual behaviour and prevents unwanted pregnancy.

3. National plans for investing in young people should be developed and implemented with the full involvement of youth. Such plans should include education, professional and vocational training, income-generating opportunities, and sexual and reproductive health information and services. Special attention should be given to gender equality and equity and to youth who are disadvantaged due to poverty, race, ethnicity, residence or disability.

4. Given the central role of the family in educating children and shaping their attitudes, while at the same time recognizing the rights of adolescents in line with their evolving capacity to take responsibility for their own behaviour and lives, in conformity with the Convention on the Rights of the Child; parents should be educated about, and involved in, providing information to adolescents so they can fulfil their rights and responsibilities in the sexual and reproductive health education of young people.

5. Measures should be taken to assure that the attitudes of health care providers do not restrict the access of young people to needed services and information including on STDs and sexual abuse.

6. Sexual education should be included in school curricula at all levels. It should be age appropriate and should begin in the home and community and continue through all levels and channels of formal and non-formal education, taking into account the rights and responsibilities of parents and the needs of adolescents. Teachers should receive adequate training in this area.

7. Sexual and reproductive health services should be provided for all adolescents who demand them.

8. Fathers have a responsibility to be positive role models and mentors for their adolescent children, particularly their daughters, in order for them to develop their self-esteem and to enable them to take responsibility for their own lives.

9. There is a need to reaffirm paragraph 5.9 of the Programme of Action that "Governments should formulate family sensitive policies in the field of housing, work, health, social security and education", within the framework of respect for the rights of families and their individual members in order to create an environment supportive of the family.

83. Some of the actions proposed for refugee and emergency situations include:

1. Refugee women and other persons in emergency situations must receive appropriate health care, including reproductive health care and greater protection from sexual and gender-based violence.

2. All health relief workers should be given basic training in reproductive health information and services.