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Countries are making real progress in carrying out a bold global action plan that links poverty alleviation to women’s rights and universal access to reproductive health. Ten years into the new era opened by the 1994 International Conference on Population and Development (ICPD) in Cairo, the quality and reach of family planning programmes have improved, safe motherhood and HIV prevention efforts are being scaled up, and governments embrace the ICPD Programme of Action as an essential blueprint for realizing development goals.

But inadequate resources, gender bias and gaps in serving the poor and adolescents are undermining further progress as challenges mount, according to The State of World Population 2004 report from UNFPA, the United Nations Population Fund.

The report, The Cairo Consensus at Ten: Population, Reproductive Health and the Global Effort to End Poverty, reviews countries’ achievements and constraints in implementing the Programme of Action, nearly half way to the 2015 completion target date. It examines actions addressing: the links between population and poverty, environmental protection, migration and urbanization; discrimination against women and girls; and key reproductive health issues including access to contraception, maternal health, HIV/AIDS, and the needs of adolescents and people in emergency situations.

The plan, adopted by 179 countries in Cairo ten years ago, sought to balance the world’s people with its resources, improve women’s status, and ensure universal access to reproductive health care, including family planning. The starting point was the premise that population size, growth and distribution are closely linked to development prospects, and that actions in one area reinforce actions in the other.

But the Cairo consensus gave priority to investing in people and broadening their opportunities, rather than to reducing population growth. Empowering women and ensuring the rights of individual women, men and young people— including the right to reproductive health and choice in determining when and whether to have children— were seen as key to sustained economic growth and poverty alleviation.

In a series of regional conferences marking ten years since the ICPD and in responses to a UNFPA global survey, governments around the world have strongly reaffirmed their commitment to the Programme of Action. Its successful implementation, they agree, is critical to attaining the UN Millennium Development Goals (MDGs) for 2015, Press Summary Countries are making real progress in carrying out a bold global action plan that links poverty alleviation to women’s rights and universal access to reproductive health. Ten years into the new era opened by the 1994 International Conference on Population and Development (ICPD) in Cairo, the quality and reach of family planning programmes have improved, safe motherhood and HIV prevention efforts are being scaled up, and governments embrace the ICPD Programme of Action as an essential blueprint for realizing development goals. (Not for release before 15 September 2004) state of world population 2004 The Cairo Consensus at Ten: Population, Reproductive Health and the Global Effort to End Poverty including ending extreme poverty and hunger, promoting gender equality and universal primary education, reducing maternal and child mortality, combating HIV/AIDS and preserving the environment.

Nearly all the developing countries surveyed report they have incorporated population concerns in their development and poverty-reduction strategies; many have established laws and policies to protect women’s and girls’ rights; and many have begun to integrate reproductive health services into primary health care, improve facilities and training and expand access. Non-governmental organizations are increasingly active in providing reproductive health services and in advocacy for implementing the Programme of Action.

Use of modern contraception has risen from 55 per cent of couples in 1994 to 61 per cent today. To reduce maternal deaths and injuries, increasing emphasis is being placed on attended delivery, emergency obstetric care and referral systems. Countries have stepped up efforts to fight HIV/AIDS through prevention, treatment, care and support. Adolescent reproductive health has become an emerging worldwide concern. And campaigns against gender-based violence are gaining broad support.

But much more must be done to ensure reproductive health and rights, including those of the world’s 1.3 billion adolescents, to promote safe motherhood and to stem the spread of HIV/AIDS.

Ten years after Cairo:

  • More than 350 million couples still lack access to a full range of family planning services.
  • Complications of pregnancy and childbirth remain a leading cause of death and illness among women: 529,000 die each year, mostly from preventable causes.
  • Five million new HIV infections occurred during 2003; women are nearly half of all infected adults, and nearly three fifths of those in sub-Saharan Africa.
  • While fertility is falling in many regions, world population will increase from 6.4 billion today to 8.9 billion by 2050; the 50 poorest countries will triple in size, to 1.7 billion people.

The tenth anniversary of the ICPD is an opportunity for governments and the international community to renew their commitments and identify ways to overcome the remaining challenges.

Population and Poverty

Some 2.8 billion people—two in five—still struggle to survive on less than $2 a day. Poverty perpetuates and is exacerbated by poor health, gender inequality and rapid population growth.

Policy makers have been slow to address the inequitable distribution of health information and services that helps keep people poor. Richer population groups have far greater access than poorer groups to delivery by a skilled attendant, contraceptives and other reproductive health services. Poor women give birth at earlier ages and have more children throughout their lives than wealthier women.

Developing countries that have reduced fertility and mortality by investing in health and education have higher productivity, more savings and more productive investment, resulting in faster economic growth.

Enabling people to have fewer children, if they want to, helps to stimulate development and reduce poverty, both in individual households and in societies. Smaller families have more to invest in children’s education and health. Rapid population growth contributes to environmental stress, uncontrolled urbanization and rural and urban poverty.

Declining fertility reduces the proportion of dependent children relative to the working-age population, opening a one-time window of opportunity (before dependent older populations become a burden) in which countries can make investments to spur economic growth and help reduce poverty.

The ICPD’s rights-based agenda for addressing the interdependence of population and poverty is therefore essential to achieving the MDGs. Most developing countries responding to the UNFPA global survey have adopted diverse strategies to address the links between population and poverty.

Footprints on the Planet

Unsustainable consumption and production patterns, coupled with rapid population growth, are taking their toll on the environment. More people are using more resources with more intensity and leaving a bigger “footprint” on the earth than ever before.

A rapidly growing global consumer class is using resources at an unprecedented rate, with an impact far greater than their numbers. Farmers, ranchers, loggers and developers have cleared about half of the world’s original forests. Three quarters of the world’s fish stocks are now fished at or beyond sustainable limits.

Half a billion people live in countries defined as water-stressed or water-scarce; by 2025, that figure is expected to be between 2.4 billion and 3.4 billion people. Fast-growing poor populations often have no other options but to exploit their local environment to meet subsistence needs for food and fuel.

Countries report taking action to address the linkages between population, poverty and the environment.

Gender plays a strong role in how resources are used and developed. At both the ICPD and its 1999 review, the global community affirmed that greater equality between men and women is essential for sustainable development and sound management of natural resources.

Migration and Urbanization

Due to continued rural-to-urban migration, the number of people living in cities is growing twice as fast as total population growth. A majority of the world’s people will be living in cities by 2007; by 2030 all regions will have urban majorities. Both megacities of 10 million or more (20 in all, 15 in developing countries) and small and medium-sized cities are growing, severely testing the limits of local infrastructure and services.

The ICPD recognized that people move within countries in response to the inequitable distribution of resources, services and opportunities. Providing social services, including reproductive health care, in poor urban areas is an essential policy response, as is meeting the needs of underserved rural communities.

There were 175 million international migrants in the world in 2000—1 in every 35 persons—up from 79 million in 1960. Many people, including a growing number of women, are seeking employment abroad, with major impacts on both sending and receiving countries. The economic effects run in both directions.

The ICPD called on nations to address the root causes of migration, especially by addressing poverty. Three fourths of countries report taking some action to address international migration; in 1994 only one fifth had done so. Some countries have tightened borders, while others aim to better integrate migrants. Many countries favour greater coordination of migration policies, but the subject remains a sensitive one.

Women’s Empowerment

Gender equality and women’s empowerment were at the heart of the ICPD vision, strongly linked to reproductive health and rights. Since 1994, more than half of all countries have adopted national legislation on women’s rights, ratified UN conventions or established national commissions for women.

Progress has been uneven. Many countries have introduced laws on gender-based violence, but these are often not enforced. Only 28 countries have increased women’s political participation. Fewer than half of all countries have initiatives in place to educate men about their and their partners’ reproductive health. Efforts promoting women’s advancement are susceptible to budget cuts. Only 42 countries were able to increase public spending on schools, and only 16 had increased the number of girls’ secondary schools.

Priorities for improving women’s status include: eliminating gender gaps in education; increasing access to sexual and reproductive health information and services; investing in infrastructure to ease women’s work burdens; reducing discrimination in employment, property ownership and inheritance; increasing women’s role in government bodies; and sharply reducing violence against women and girls.

Reproductive Health and Family Planning

Gaps in reproductive and sexual health care account for one fifth of the worldwide burden of illness and premature death, and one third of the illness and death among women of reproductive age.

The ICPD’s broad concept of reproductive health and rights, including family planning and sexual health, continues to gain support. This year the 57th World Health Assembly recognized the Cairo consensus and adopted WHO’s first reproductive health strategy to accelerate progress towards the MDGs.

Family planning enables individuals and couples to determine the number and spacing of their children—a recognized basic human right. Some 201 million women, especially in the poorest countries, still have an unmet need for effective contraception. Meeting their needs would cost about $3.9 billion a year, and prevent 23 million unplanned births, 22 million induced abortions, 142,000 pregnancy-related deaths (including 53,000 from unsafe abortions) and 1.4 million infant deaths.

Important progress has been made towards the ICPD goal of universal access to reproductive health services by 2015. Greater attention has been given to reproductive rights in laws and policies. Many countries have reoriented services and stepped up training to improve quality, expand family planning method choices, and better meet clients' needs and desires. Efforts have been made to integrate treatment of sexually transmitted infections (STIs) with other services, and to involve men more in protecting their own and their partners’ reproductive health.

However, donor support for reproductive health commodities has declined over the past ten years, creating a growing gap between needs and supplies. Between 2000 and 2015, contraceptive users in developing countries are expected to increase by 40 per cent.

Maternal Health

Obstetric complications are the leading cause of death for women of reproductive age in developing countries, and constitute one of the world’s most urgent and intractable health problems. Despite progress in a few countries, the issue has not been given high priority and the global number of deaths per year has not changed significantly since 1994.

Poverty dramatically increases a woman’s chances of dying. The lifetime risk of a woman dying in pregnancy or childbirth in West Africa is 1 in 12. In developed regions, the comparable risk is 1 in 4,000.

Most maternal deaths stem from problems that are treatable but hard to detect. Reducing deaths requires expanded access to skilled attendance at delivery, emergency obstetric care for women who experience pregnancy complications, and referral and transport systems so those women can receive needed care quickly.

Skilled personnel assist half of all deliveries in developing countries, but just 35 per cent in South Asia and 41 per cent in sub-Saharan Africa.

Millions of women survive childbirth but suffer illness and disability. One of the most devastating is obstetric fistula, an internal injury caused by obstructed labour that leaves women incontinent and often ostracized. UNFPA and others are working to prevent fistula, advocating against child marriage and promoting increased access to emergency care.

Since the ICPD, most countries have reported taking actions to promote safe motherhood. Countries are also increasing access to family planning services to reduce unintended pregnancies. At least 40 countries have initiated post-abortion care programmes. Complications from unsafe abortions are a major cause of maternal death; the ICPD urged greater attention to this neglected issue.

Preventing HIV/AIDS

In just over two decades, the AIDS pandemic has claimed 20 million lives and infected 38 million people. This number could rise greatly if countries do not pursue strategies to prevent HIV. Fewer than 20 per cent of people at high risk of infection have access to proven prevention interventions.

The consequences of AIDS are far-reaching. In some areas of sub-Saharan Africa, 25 per cent of the workforce is HIV positive. Studies show that if 15 per cent of a country’s population is HIV positive, its GDP will decline by 1 per cent a year.

Since most HIV transmission is through sexual contact, reproductive and sexual health information and services provide a critical entry point to prevention, by: providing education on risks to influence sexual behaviour; detecting and managing STIs; promoting the correct and consistent use of male and female condoms; and helping to prevent mother-to-child transmission. Linking prevention efforts and voluntary HIV testing and counselling with existing reproductive health services can improve outreach, reduce stigma and save money.

The ICPD recognized that discrimination and violence make women and girls especially vulnerable, and efforts to address this gender inequality are growing. Infection rates among young African women aged 15-24 are two to three times higher than among young men. Married women are often unable to negotiate condom use even when they know their husbands have multiple partners.

Means to treat HIV have improved in the last decade, but the vast majority of those infected lack access to life-saving antiretroviral therapy. WHO and UNAIDS aim to bring treatment to 3 million people by 2005 and reduce drug costs. Increased availability of treatment will bring more people into health facilities where they can be reached by prevention messages.

Three fourths of countries answering the global survey reported having a national strategy on HIV/AIDS. New policies and coordination with NGOs mark positive changes in many countries, but many in at-risk groups are not being reached. Donor funding for condoms is far below what is needed, and education efforts are inadequate.

Serving Adolescents and Young People

Since 1994 and especially in the past few years, countries have made significant progress in addressing the often-sensitive issues of adolescents’ reproductive health, including needs for information and services that will enable them to prevent unwanted pregnancy and infection.

Young people aged 15-24 account for half of all new HIV infections—one every 14 seconds—with young women especially at risk. Worldwide, there is a trend towards later marriage; growing numbers of adolescents are sexually active before marriage, often without the knowledge or means to protect themselves.

In a number of countries, early marriage and childbearing are still the norm for girls, usually to much older men. Married girls are less likely than others their age to finish school, and more likely to contract HIV or another STI.

UNFPA and other organizations work in a variety of ways to teach young people about reproductive health, in combination with developing life skills and job training. Reaching those who are married, those living in rural areas and poor urban settlements, and those out of school is a key priority.

Ninety per cent of countries report having taken steps to address adolescent reproductive health. But efforts lag far behind needs, and successful interventions need to be scaled up dramatically.

Helping Communities in Crisis

Since the ICPD, attention to the reproductive health needs of women made vulnerable by war and disaster has increased greatly.

A quarter of the tens of millions of refugees in the world are women of reproductive age; one in five of these women is likely to be pregnant. Death from complications during childbirth is far too common in disaster-stricken countries where women have no access to maternal health care.

Rape and gender-based violence occur more often during war, and victims of this abuse are more likely to contract an STI, including HIV/AIDS. Stable relationships and family units may break apart as disaster strikes. Young people are greatly affected by such changes, leading to a rise in teen pregnancy, unsafe sex and abortions.

UNFPA and other humanitarian groups respond to emergencies by providing basic materials needed for safe childbirth, and protection from unintended pregnancies and STIs. They also support education campaigns and camp safety measures to prevent sexual violence, and provide counselling and treatment for those who have been violated.

Priorities for Action

Successful action to implement the Cairo agenda and combat poverty depends on adequate funding and effective partnerships. Since the ICPD and its five-year review, partnerships have developed between governments and a broad range of civil society organizations, including women’s community groups, human rights organizations, trade unions, universities, private health providers and parliamentarians.

But resources have fallen short. Donors agreed to provide $6.1 billion a year for population and reproductive health programmes by 2005, a third of total needs. In 2002 (the latest year with available figures), contributions were around $3.1 billion—only half their commitment.

Developing country domestic expenditures for the ICPD package in 2003 were about $11.7 billion. But a large proportion of this comes from a few large countries. The poorest countries depend heavily on donor funding for family planning, reproductive health and other population-related activities. Additional funds are needed to combat the HIV/AIDS pandemic; funding in this area is increasing but still far less than needed.

Policy priorities for action in the next ten years include better integration of population into national planning; broadening programmes to meet the needs of the poorest population groups; strengthening urban planning to provide services in marginal communities; investing in rural development; reforming laws and policies to end discrimination against women; and making civil society participation a routine part of institutional practices.

Delivery of comprehensive reproductive health and family planning services needs to be strengthened significantly, through improvements in capacity, supply chains and quality. Safe motherhood interventions should be scaled up and promoted. HIV/AIDS interventions must be linked more effectively to other components of reproductive health. Efforts to reach all adolescents in need of information and services, including those married and those not in school, should be increased.

Ten years on from the ICPD, the world needs its vision of human-centred development more than ever. Today’s challenges—including security concerns, the continuing spread of HIV/AIDS, and persistent poverty alongside unprecedented prosperity—make it imperative to carry out the Cairo agenda so that its dream of a better future for all is realized.