Reproductive Health and Rights: Perspectives for Further Development in Africa
27 July 2010
27 July 2010
Professors and Students,
Ladies and Gentlemen,
I am honoured to be in the dynamic city of Kampala, and to be hosted by a remarkable institution. Since its establishment, Makerere University has stood as a beacon of learning, enriching the growth and development of Uganda and the African continent. With the motto, we build for the future, this university has been home to many post-independence African leaders, thinkers and writers, and some of my United Nations colleagues.
Africa on the move
We meet at a time of renewed hope in Africa, on the heels of the successful World Cup in South Africa. Not since the historic inauguration of President Nelson Mandela 16 years ago have so many people from around the world watched and cheered as events unfolded in Africa’s southernmost nation. In the ongoing Africa Union Summit in Kampala, Presidents and Heads of State congratulated South Africa for the success of the whole event and repeatedly said, “You made Africa proud.”
The renewed Africa is also demonstrated by the theme of this Summit - Maternal, Infant and Child Health - the first time Heads of State and Government devote their time to talk about a subject that is considered a “soft subject” that does not come to the strategic level considered suitable for such an august gathering. And I congratulate the African Union for convincing the Heads of State and Government to adopt this theme and to engage in a dialogue around it. Maternal, infant and child health is one of the most strategic issues that should concern the leadership of Africa because this issue is about the reality of the present and the hopes for the future of this continent.
The theme of struggle, change and hope continues in the renewed Africa as many countries celebrate 50 years of independence.
As people around Africa celebrate 50 years of independence, they are thinking about the meaning of freedom and examining the achievements and the failures of their countries during the past half century. They are also looking ahead to the next 50 years and what the immediate future holds for the present generation, and what it will bring in the longer term for their children and their grandchildren.
Throughout my 35-year career in the United Nations and especially during the last decade as UNFPA Executive Director, I have gotten to know the spirit of Africa. And I have established an emotional tie with this continent and its people. I keep on saying: Africa is moving and the change deserves celebration.
It is in this spirit of celebration and reflection that I address you today about reproductive health and rights and perspectives for further development in Africa.
Although reproduction is surrounded by myths and taboos and often shrouded in silence and great privacy, it affects every single human being with a clear impact on the future prospects of individuals, communities and nations.
Today I will explain why reproductive health and rights are an indispensible part of the journey of hope and renewal for Africa. These issues lie at the very heart of human security and development. They have also become highly politicized and need to be deconstructed in order to respond to people’s needs, especially women.
After participating in the African Union Summit, I can testify to the fact that the leaders of Africa have already began the process of deconstructing and demystifying sexual and reproductive health, as one after the other took the floor to speak about their commitment to reproductive health, including maternal health and family planning.
The International Conference on Population and Development (ICPD)
To gain a clearer understanding of the concepts of reproductive health and rights, we have to go back to the 1994 International Conference on Population and Development that was held in Cairo. It was one of the groundbreaking United Nations meetings of 1990s that set an international agenda for population as it relates to human rights and development.
Participants engaged in heated discussions about the interrelationships between population, economic growth and sustainable development. They spoke about the empowerment of women, the role and forms of families in a changing global environment, about population growth and family planning, and women’s and children’s health and HIV and AIDS, and about young people. They discussed urbanization and migration, the plight of refugees and the displaced and the protection of our environment.
And for the first time at a huge global conference, the private became public. The conference opened public dialogue and international negotiations, and shined a media spotlight on the private relationship between men and women. This naturally brought to the forefront questions of power relations, morality, religious beliefs and interpretations, and customs and cultural values regarding the roles of women and men within their families and societies.
At the end, after much push and pull, 179 governments agreed on a 20-year Programme of Action to promote the well-being of present and future generations. The Cairo Conference was truly a watershed event. The focus shifted from a top-down demographic approach, associated with population control managed by the governments, to a bottom-up human rights-based approach, emphasizing individual informed choice. The Programme of Action places human beings, rather than human numbers, at the centre of all development actions.
It defines reproductive health as a state of complete physical, mental and social well-being in all matters related to reproduction and it also includes sexual health, the purpose of which is the enhancement of life and personal relations.
It defines reproductive rights as human rights. And it explains that reproductive rights rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, timing and spacing of their children, and to have the information and the means to do so, and the right to attain the highest standard of intimate relationships.
Leaders agreed for the first time that every person has the right to sexual and reproductive health. And they agreed that this right, along with universal education, the empowerment of women and gender equality, are decisive factors to reduce poverty, facilitate sustainable development and strengthen the institutions of democracy. And they set 2015 as the targeted date to achieve this agreement.
Investing in women is smart economics
There is now a mountain of evidence to show that investing in women’s health and rights is one of the best investments in development. When women are healthy and empowered, their newborns are more likely to survive, children to thrive and these benefits carry through to the next generation.
When women enjoy equal rights and opportunity, they contribute to peace and security.
Africa is better off with strong women leaders like Ellen Johnson-Sirleaf, the first African woman head of State who is leading her war-torn country to peace and recovery. Africa is stronger with Rwanda boasting the world’s highest percentage of women members of parliament, and improved standards of health and education.
A small investment in a girl's education reaps enormous rewards for an entire society - whether she becomes a president, doctor or learns to read. A single year of secondary schooling can translate into an increase of 10 percent to 20 percent in future wages.
Here in Africa, women farmers, traders, teachers and mothers make indispensible contributions to the well-being of their families and nations. Yet they lack healthcare and education and access to resources, which holds back progress for all. It's time that we rethink our investment in the potential of more than half of the population so that they can enjoy equal opportunity.
Reproductive health information, services and rights play a pivotal role in expanding women’s choices, opportunities, and autonomy. This enables women to participate more actively in both public and private life and contribute to greater social, environmental and economic progress for all.
That is why yesterday at the AU Summit, the leaders of Africa agreed that financial resources that flow to the health and education of girls and boys, and girls in particular because of the multiplier effect, are an investment and not expenditure.
I would like now to address the three areas of reproductive health—information, services and rights, to bring greater clarity to this matter.
First, Empowerment and equality: Information and knowledge
The provision of sexual and reproductive health information is empowering in and of itself. Reproductive health information removes the myths and misconceptions that typically surround issues of sexuality and reproduction. There is the myth, for example, that sexual relations with a virgin can cure a man of HIV and AIDS. There is the myth that female genital mutilation/cutting is required by the Islamic faith. And there is the myth that if a girl jumps up and down after intimate relations then she will not get pregnant.
Providing factual information is the only response to such myths; this empowers individuals with knowledge—basic yet fundamental knowledge that is extremely useful, relevant and powerful. It reduces ignorance, stigma and fear, and increases our ability, as human beings, to engage in conscious, healthy behaviour and relationships with each other.
Studies show that, contrary to popular belief, sexuality education that is context and age specific does not increase promiscuity and high-risk behaviour. On the contrary, it leads to more responsible and healthy behavior and even delayed sexual activity by young people.
We also know that sexuality and gender relations are closely interrelated. When the values of mutual respect and trust are instilled during formative years, they enhance respectful and harmonious partnerships between men and women, within families, and this fosters broader equality throughout the society.
Second: Empowerment and equality: Access to reproductive health services
Knowledge and information become even more powerful when they are combined with access to a comprehensive package of reproductive health services that is relevant to women through a life cycle approach- as young girls, adolescents, during and after the reproductive years. This package of reproductive health includes family planning, maternal healthcare, the prevention and treatment of sexually transmitted infections, as well as the prevention, counseling, testing, and treatment of HIV.
Family planning services enable women not only to plan their families but also to plan the rest of their lives. If a woman cannot decide voluntarily on the number and spacing of her pregnancies, then she cannot decide on anything in her life. This right is fundamental to a woman’s ability to exercise her full rights, to enjoy increased opportunities in both public and private life and to participate fully in civic life.
The point I would like to emphasize is that here in Africa, as in other regions, there is a huge gap in access to these services between the rich and the poor, and rural and urban populations, and between the educated and uneducated. In fact, of all health indicators, maternal mortality displays the highest inequality between rich and poor, both between and within nations. And this has a devastating impact on individuals, families and communities. Lack of access to any services is the hallmark of poverty and it is a denial of the right to health and all other rights.
As a result, we see that poor, uneducated young women have the least information and services, and the highest rates of death or injury during pregnancy and childbirth. A woman’s risk of dying from pregnancy-related causes is estimated to be one in seven in Niger compared to one in more than 17,000 in Sweden.
And there is a high “unmet need” for family planning; more specifically here in Uganda, 41% of women of reproductive age have indicated that they would like to plan their families but have no access to such services, which then leads to unwanted pregnancies and unsafe abortion. And unsafe abortion is a serious public health issue; it is the first killer of girls between the age of 15 and 24 in Africa.
Governments agreed that the best way to reduce recourse to abortion is to expand access to family planning and to provide compassionate counseling when there is an unwanted pregnancy and post-abortion care. It was also agreed that abortion is to be decided in each country, and where it is not against the law, it should be safe and accessible.
I believe that this issue deserves open, mutually respectful and civil debate. It is unfair that reproductive health and rights are sometimes equated with, or used as a euphemism, for abortion. This position hampers efforts to advance public health and save women’s lives. It also denies women their right to respect and compassion.
Today only 17% of women of reproductive age in sub-Saharan Africa use a modern contraceptive. But about 60% of women in the region who want to avoid a pregnancy are not using family planning or are using a traditional method. In addition, almost 80 % of women who need care each year for complications of pregnancy and delivery do not receive it. If reproductive health services were provided to all women in need, maternal deaths would be reduced by 70%, newborn deaths would be cut by nearly half, and 750,000 lives would be saved each year.
Achieving universal access to reproductive health requires national commitment and funding, a functioning health care system, integration of sexual and reproductive health services in a life cycle approach with HIV/AIDS into all levels of health care, especially primary or community health care, with a targeted focus on reaching and serving the poor, the marginalized and the vulnerable.
Third: Empowerment and equality: Reproductive rights
These rights are human rights and they are fundamental to self-determination.
Women cannot make greater progress unless they have the ability to lead healthy and productive lives and to make informed decisions concerning marriage and reproduction free of coercion, discrimination and violence. And these rights must be protected by law and enforced for equality to take effect.
Clearly, legal provisions are required to eliminate discrimination between men and women and to criminalize and end impunity for sexual abuse and violence.
In many cases, globally and not only in Africa, women and girls are discriminated against, not only on the basis of their being female, but also for being pregnant.
We have to ask ourselves: What does the future hold for a girl who is expelled from school because she has an unwanted pregnancy?
What do rights mean to a pregnant woman who is HIV positive and is forced to have an abortion?
What does freedom mean for a girl who is forced to marry a man who is a total stranger or much older than she is?
What does dignity mean to a girl (or for that matter boy) who is abducted by armed groups and forced to exchange sexual favours for his or her own life?
People need legal protection and support to exercise their reproductive rights.
Laws have to be enforced and this requires a strong legal system, a conducive policy environment and a supportive community. Even though laws have been enacted in many countries, for instance, to ban child marriage and female genital mutilation and cutting, these practices continue to exist because they are deeply rooted in the culture. Laws are required but they are not sufficient. Change in the mindset and behaviours is required.
Human rights, gender and culture
Tackling the complex issues of the right to sexual and reproductive health requires a comprehensive approach that addresses human rights, gender and culture together.
We know that cultures are not static; they are constantly changing because they are made by people and people can change them. Many Leaders at the AU Summit referred to culture as an obstacle. But we agreed that culture can be a force for positive change if we focus on how to mobilize people so that they bring change themselves. Change can never be imposed from the outside. Change has to come from the communities themselves. Through this transformation, human rights can be well understood and articulated in a contextual manner.
One of the great contributions of the 20th century is the articulation of universal human rights and dignity and the vision that all human beings are born free and equal.
Today many people are creating a culture of human rights. They are opening space for public dialogue, speaking freely about harmful practices and changing social norms and values. This is happening in countries throughout the world—within families, places of work and worship, and within communities. And this is happening right now—in this august University.
Reproductive health and the Millennium Development Goals
The critical importance of reproductive health to development has been acknowledged at the highest level. Five years ago, at the 2005 World Summit, leaders recognized that it would not be possible to achieve the Millennium Development Goals and eradicate extreme poverty, improve children’s and women’s health, promote gender equality, halt HIV and ensure environmental sustainability without guaranteeing universal access to reproductive health.
Accordingly, in 2007, universal access to reproductive health was added as a target in the Millennium Development Goals framework, under MDG5 to improve maternal health. The goal has two specific targets: to lower maternal deaths by 75% from 1990 levels, and to ensure universal access to reproductive health by 2015.
I am pleased to report that UNFPA and our sister agencies, WHO, UNICEF, UNAIDS and the World Bank, joined by UNAIDS, are working together in a coherent way, I hope, to mobilize support and scale up national efforts to make reproductive health for all a reality.
Today poor sexual and reproductive health is a leading killer in Africa and the consequence are felt by women, couples and families every day.
With 11 percent of the world’s population, Africa accounts for more than half of maternal and child deaths and nearly three-quarters of deaths related to HIV and AIDS. Africa has the highest burden of disease in the world but also the lowest investment in the health sector.
The good news is that there is growing momentum and action to save lives and protect the right to health. There are growing voices for change. It has grown from a whisper to a shout that no woman should die giving life. And this was repeated by every leader throughout yesterday and today.
Countries on this continent are making progress guided by the Maputo Plan of Action for Sexual and Reproductive Health and Rights, which has as its foundation the Programme of Action for Population and Development. I applaud countries throughout the continent that have launched national CARMMA (Campaign to Accelerate the Reduction of Maternal Mortality in Africa).
Momentum is building
The G8 Summit at Canada pledged to mobilize an additional $7.5 billion over the next five years to significantly reduce the number of maternal, newborn and under-five child deaths in developing countries. They pledged to promote integration of HIV and sexual and reproductive health, rights and services within the broader context of strengthening health systems.
Integrating services for sexual and reproductive health and HIV and AIDS is cost-effective, saves more lives, and brings the highest return on investment.
Two weeks ago, on the eve of the International AIDS Conference in Vienna, I was so pleased to hear that HIV prevalence among young people in Africa is falling in 16 of the 25 countries most affected by AIDS and young people are leaders in the prevention revolution.
Momentum is building. This September, UN Secretary-General Ban Ki-moon will host a special event to launch a Joint Action Plan to Improve the Health of Women and Children. At the United Nations Summit on the Millennium Development Goals, he will highlight government commitments. African leadership is critical for our collective success. Again in the African Union Summit, leaders were encouraging each other to reassert their commitment at the global level.
By making reproductive health and rights a priority, we can ensure safe motherhood and create an HIV-free generation. Success in one area leads to success in the other.
At UNFPA, we are proud of our partnership with Africa. Our vision is that every child is wanted; every birth is safe, every young person is free of HIV, and every girl and woman is treated with dignity and respect.
When governments invest in reproductive health, together with education and employment, they can put their country on a path to prosperity. When a country moves from high to low rates of death and birth, through a demographic transition, a window opens to accelerate economic growth.
This happens when there is a large working age population with relatively few dependants to support. Economists have attributed as much as 40 per cent of East Asia’s per-capita income growth between 1965 and 1990 to its beneficial population structure, which was a result of an early investment in the health and education of young girls and boys as well as in reproductive health including family planning. And this brings me to my next point.
Population growth in Africa and unmet need for family planning
Today Africa has the fastest growing population in the world and this trend affects health, poverty, food, water and adapting to climate change. In fact, poor women, who are the least responsible for climate change, are bearing the worst of its consequences as they strive to provide food, water, and safety for their families.
The United Nations data projections tell us that Africa’s population will double from 1 billion to 2 billion by 2050. But even this rate of growth, which is the medium projection, assumes a significant decline in the fertility rate – and that will only be achieved if all women who want to plan their families have access to the required services.
Today one in four women in sub-Saharan Africa have expressed the desire to use contraceptives but do not have access to them. When women can have children not too early, not too late and not too often, they are contributing to slowing population growth, which buys time for development programmes to meet the needs of the population.
If there is no collective action, on the part of national governments and the international community, in responding to the voices of poor women and providing universal access to reproductive health services – then the projection is for Africa’s population to triple to 3 billion people in the next 40 years.
It is not about numbers but about people: The case for young people
Another related and distinguishing aspect of Africa’s population structure is its large and growing youth population. Today the median age of a person in Africa is 20 years, half of the median age in more developed regions. Six in 10 Africans on the continent are under the age of 25, and the choices and opportunities they enjoy will determine our common future.
The challenge of providing basic services and employment opportunities will be quite substantial to say the least, in countries across Africa, like Ethiopia, Kenya, Malawi, Niger and here in Uganda - where the populations will at least double, sometimes triple and, in Niger, quadruple.
The young generation of today is not part of the 1960s struggle for independence. They are a new generation that views independence as freedom and opportunity. They are searching for hope and looking to become leaders themselves.
This generation is connected to others around the world as never before. Today in Africa there are 450 million mobile phone subscriptions compared to just 10 years ago when there were only about 16 million. People are using their mobile phones to make money transfers. Fishermen and farmers can get quick updates on sudden changes in the weather forecast, children can access online education, and villagers can get information on local medical care. And yet women, infants and children are dying of preventable causes.
This is a new world unlike anything we have seen before and it is filled with both promise and peril.
Young people have high expectations. Like the many students in this great university, they can strive for excellence, energized by the belief that there is a place for them in the world where their knowledge and talents will be utilized and rewarded. Or, if that dream does not come through, they will look for better lives away from home and what a difficult decision this will be and what a loss to Africa. Or they can be destructive, both to themselves and their communities.
As jubilee celebrations of independence continue, it is time to recognize the past and also take responsibility for the future. It is time to invest in a new life for Africa’s women and young people.
While the 20th century marked the end of apartheid and the period of decolonization, I believe that the key human rights struggle of the 21st century is the struggle for equality and the rights of women. As the great leader Nelson Mandela said, “Freedom cannot be achieved unless women have been emancipated from all forms of oppression.”
Mandela and others have taken their place in history by marching for freedom and tearing down the oppression of apartheid and colonization. Now is the time to tear down all forms of discrimination against women—what some call gender apartheid, and usher in the first century of equality between women and men.
Now is the time to support the rights of young people and embrace them as partners and leaders in building a more just and prosperous future.
This requires bold leadership. The gradual advances that have been made now are threatened by the recent financial and economic crisis. If we are to make motherhood safe for all women and create an HIV free generation, the pace of progress must be more than doubled over the next five years, in a context of scarcer resources.
The Heads of State and Government of the African Union have adopted notable policy instruments over the past few years that include the African Health Strategy, the African Regional Nutrition Strategy, the Continental Policy Framework and its Plan of Action on Sexual and Reproductive Health and Rights (Maputo PoA), the Abuja Call for Accelerated Action Towards Universal Access to HIV/AIDS, Tuberculosis and Malaria Services, the Summit Decision on Accelerating Action for Child Survival and Development in Africa to Meet the MDGs, the Call for Accelerated Action Towards Africa Fit for Children, the African Charter on the Rights and Welfare of the Child, the Protocol on the Rights of Women and The African Youth Charter.
Africa has all the right policies and plans of actions – it now must put all its energies on implementation and scaling up programmes to cover as many of those who deserve and have the right to a better life. Many of the Heads of State and Government at the African Union Summit said that they do not need any more strategies or policies; they want action.
Taking this commitment forward, African leaders will have to make reproductive health a priority and devote 15 percent of their budgets to health as they agreed in Abuja. They also need to invest resources in training doctors, nurses and midwives to tackle the gap of 2.4 million health workers needed in Africa. And they also must invest in their retention in their work place.
The real challenge in front of the leaders of the region is to give real sense to the independence that is being celebrated. We celebrate when women live while giving life- the very basic and yet the most honoured of all human functions. This is the renewal that Africa is capable to achieve and this is the renewal to which each one of you in this gathering is, hopefully, committed. I know that Africa is on the move and I have faith in its capacity to achieve the dreams of its people through and by its people, women and men, young and old.