Sexual and Reproductive Health and Rights: the Next Twenty Years
July 08, 2013
Dr. Nafis Sadik's Keynote address at the ICPD International Conference on Human Rights
Thank you for your warm welcome. And let me say a special ‘thank you’ to our hosts, the Government of the Netherlands, whose strong leadership and warm participation has been such a strong and lasting feature of the last 20 years.
I think that when you applaud me, you are really applauding yourselves. I have already met so many of you who were at Cairo, and I can see so many more here in the audience. And I have been very proud to meet many of you who were not at ICPD, who are working hard to turn its great promises into reality. You all deserve the credit for what happened at Cairo, and what has happened in the years between. And you will earn great credit for your work in the future.
For that is the true achievement of Cairo – not only what the conference completed, but what it began. It opened doors and showed us the paths that we are still following today.
What ICPD meant then and what it means today
ICPD certainly completed some unfinished business. The Cairo consensus firmly nailed down the coffin of so-called “population control”, and made clear once and for all that population and development policies are inseparable. It settled an old argument between global needs and national sovereignty: countries following the Cairo agenda, acting of their own volition and in their own national interests, will also serve the global imperative of slower and more balanced population growth.
The consensus settled another old argument – between development demands and human rights. To follow the Cairo agenda is to respect and promote human rights. When we talk about “reproductive rights” this is what we mean. It’s the difference between people as objects, and people as agents: between regarding people as pawns on the policy chessboard, and recognising them as the players, the decision-makers, the drivers of policy; autonomous individuals intimately concerned with the direction of their own lives.
Under these conditions women, especially, enjoy better health and live fuller lives. Boys and girls alike grow up knowing that they can make their own choices in life. Girls whose rights are understood and protected within the family become women with a strong sense of autonomy, who value themselves, their partners and the rights of others.
Under these conditions, girls finish school, marry later and have the children they want, and no more. Large families are no longer the norm, and population growth slows down. A window opens for investment and economic development.
This is the path that the consensus showed us: the path to considering population and development policies – and especially sexual and reproductive health – from the standpoint of human rights, and especially women’s rights. Following that path, individuals and countries find their way to rights-based development, starting with the elimination of extreme poverty and inequality. It starts with a woman. It starts with a girl.
Moving towards consensus
The history books say that consensus at Cairo was hard to achieve. Well, it only took 20 years… in fact the 1974 World Population Plan of Action, the first-ever such document, mentions women only twice, both times in the context of fertility. Ten years later, the Mexico City recommendations included one (Recommendation 11) on the status of women, which says, in its entirety: “Improving the status of women and enhancing their role is an important goal in itself and will influence family life positively.” Between Mexico and Cairo, we came a long way.
There was of course some controversy in Cairo – that’s how we got so much media coverage. But the major controversy was only about one paragraph, and there was an extraordinary degree of consensus on the core issues – 85 per cent of the final document in fact – before the conference even started.
That broad consensus was the result of wide consultation in countries and regions, with the active participation of civil society. By the time ICPD arrived, we had not only a separate NGO forum, but NGO representation in many national delegations – which was strongly encouraged (let me add) by the Netherlands Government. To my mind that was the secret of our success. The physical presence of so many dedicated and committed people, many of them young, many of them women, meant that delegations were well informed about real-world concerns and priorities, and what it would take to make a real and lasting difference in people’s lives.
The result was a Programme of Action which was, and still is, very clear and highly practical. It says in plain language what needs to be done; who should do it; by what time; what it will cost, and who should pay for it. No excuses.
Where are we now, and what should we do?
So why are we here today with so many of the Cairo goals still far from completion? Why do so many girls start but not finish school? Why are so many adolescents so ignorant of the basic facts of sexuality and reproduction, including how to protect themselves from HIV and AIDS? Why are so many girls married before they are old enough to make their own decisions? Why are so many women, married and unmarried, vulnerable to gender-based violence – including FGM, fistula, and infection with HIV? Why do so many women still suffer and die from complications of pregnancy and childbirth? Why is unsafe abortion still a major cause of maternal mortality and disability?
Why, above all, are countries still so far from the central goal of universal access to affordable and appropriate sexual and reproductive health services? Most services are directed at married women with children, including sexually transmitted disease and AIDS prevention, GBV and cervical cancer screening. They do not reach the unmarried, the childless, adolescents – whether married or not – and most men. They do not reach people who may be outside mainstream society – young people out of school, IDU’s, sex workers and the LGBT community.
We know that until these conditions are met, the goal of gender equality with full human rights for all will never be reached. We know that rights-based development will never become a reality.
I do not underestimate the great progress that countries and women themselves have made since ICPD. There is a great deal that we can be proud of. The international context for gender equality and human rights has never been stronger. The Millennium Development Goals recognise the centrality of sexual and reproductive health to ending poverty – although it took a little education before everyone got the message. It is ironic, really, that sexual and reproductive health wasn’t among the Goals as originally adopted, since in effect all the Goals reflect work done at ICPD.
Among other examples in the UN sphere, the Commission on Population and Development and the Commission on the Status of Women have recently adopted strong rights-based positions on young people and on gender-based violence. The Committee on Human Rights has adopted a resolution on preventable maternal mortality, morbidity and human rights.
Similar progress is noted at regional and national level, notably the Maputo Protocol of 2003, which provides broad protection for African women’s rights, including their reproductive rights. Many countries can show progress in legal and constitutional protection, in particular for women’s rights, though the rights of LGBT people are still not universally protected, or even recognised.
But progress on the ground, real change in the lives of ordinary women and men, is far harder to see. There has certainly been a welcome surge in global contraceptive prevalence, for example; but a handful of large countries, and elites in most countries, account for the bulk of the increase. Elsewhere, especially for poor women in poor communities, reproductive life has not changed very much since their mothers’ or grandmothers’ times. Affordable modern contraception is hard to find; women accept that unintended pregnancy is a normal hazard of their lives, and they accept the risks that go with it. It is very good news that maternal mortality rates have fallen by 40 per cent since ICPD – but that is far short of ICPD’s goal of 75 per cent. Child marriage affects the lives of 14 million children under 18 every year: many of these girls will be pregnant before they are fully prepared for childbirth. Many will suffer agony and death as a result. Most countries are far short of the goal of involving all sectors of the community, especially women and young people, in making the policies that will shape their lives.
Unsafe abortion – the cause of so much heated discussion in Cairo – remains a major cause of maternal death in many countries. They have made little progress in addressing it, or the underlying issues of ideology and prejudice. There is a rational discussion to be had in every society about the conditions under which abortion is permissible. But whatever the outcome, wherever abortion is legal it must be safe. That was the minimal consensus position reached at ICPD, and in its time it was a breakthrough. However, the consensus does not address the rights of the woman who needs an abortion where it is not legal. Pregnancy should not entail an avoidable risk of death: that is a simple extension of the human right to health. Illegal abortion is unsafe almost by definition. Surely it is time to recognise and address this urgent question, not only within countries and cultures but at the global level?
Let me offer some further suggestions on how to reach the goal of universal access to sexual and reproductive health.
First, SRH programmes must move away from the MCH delivery model. MCH programmes are strongly established in most countries and they can be very effective. The problem is that they are oriented almost entirely to married women with children. Women in other categories including childless married women and unmarried women, and of course men, are effectively excluded. In practice if not in theory MCH has become a silo. If all women and men are to have access to the full range of services, programmes must reach out to them. The best way to do this is as part of an integrated health system combining curative and preventive services, including MCH. Countries will arrive at their own best practices, but it is a perfectly practical solution if there is the will to do it.
Second, although the intention of ICPD, among other things, was to ensure that family planning was available to everyone who needed it, family planning information and services have slid far down the public policy agenda, both in the donor community and among medium- and low-income countries. Recent efforts to restore focus, such as the London summit on family planning, are very welcome, but the fact remains that demand among women of reproductive age is outstripping the ability of countries to meet it. Programmes are at best, marking time. In many places they are falling behind.
Perhaps in a way we are victims of our own success. Total fertility and population growth rates have gone down globally and in many countries, so some people assume that the urgent need has passed. Of course we know better: if the focus is on women rather than demographics, the need is more urgent than ever. Most of the women with unmet need for family planning are poor, and many are illiterate; they are being held back while the rest of the world moves on. In the 69 poorest countries, with 73 per cent of the unmet need, the number of women not using modern methods actually increased between 2008 and 2012.
Countries can fill this gap without new technologies or expensive delivery systems; while new contraceptive methods would be welcome, the ones we have are perfectly adequate. Resources are lacking, of course – but assigning the small amounts needed is a question of political will, not economics. Meeting unmet need in the 69 poorest countries would have cost just over $2 billion in 2012. On Wall Street, that sort of money is a rounding error. Peanuts, really.
Third, long experience and much research has shown that sexuality education in adolescence is the foundation of healthy sexuality in adult life. Yet only a third of adolescents worldwide know how to prevent HIV, for example, and millions of young women go into marriage without even the most basic knowledge of sexuality and reproduction. Young people have the right to know about their own bodies so they can decide their own futures. How will that happen unless they have systematic access to the information, in school and afterwards? Countries and the international community must pick up the challenge they accepted in Cairo – to ensure not only that all children are educated, but that they are educated about their sexual and reproductive health, and how to protect it.
Finally, men. Every cause needs a champion, and sexual and reproductive health and rights is no exception. Women’s organizations, with their increasing power and reach, have picked up the challenge. But men are half the world, and we need influential men to lead their peers, encourage them to pick up their responsibilities, and become full partners in the fight for human rights. In a word, we need leaders.
Barriers to implementation
Leadership from many quarters made the ICPD consensus possible, notably from the Netherlands, whose UN Ambassador Nicolaas Biegman was such a driving force in the preparatory stages. The United States was the “indispensable nation”. Had it not been for US commitment, personified by Senator Tim Wirth and the personal involvement of Vice-President Al Gore, the outcome would have been far different. The participation of so many heads of state and government gave status and prestige to the conference and reinforced the strength of the consensus.
We left Cairo with a sense of high achievement and a strong feeling that the major barriers were behind us.
That made the loss of momentum after ICPD even more disappointing. I don’t think we were too far in advance of world opinion: the Beijing Women’s Conference took the consensus even further in the direction ICPD had pointed; regional and global five-year reviews endorsed the Programme of Action and strengthened it in many respects. But as I have already noted, the MDGs as adopted in 2000 did not include the key element of universal access to reproductive health, and after 2000 progress was certainly held back by the new US administration and other conservative governments. Perhaps their determined opposition empowered some who had been lukewarm or even in their hearts opposed to the consensus, and discouraged some of the more timid from taking the actions they had agreed. Increased funding for the ICPD agenda fell far below the agreed levels, and international support for family planning in particular fell, even in dollar terms.
The growing HIV and AIDS menace certainly held back the ICPD agenda: but so did the general practice of isolating HIV and AIDS prevention and treatment from public health institutional mechanisms and structures. Progress towards integration has been made, but silos and vertical programmes are still with us today. They have led to much unnecessary expenditure of human and financial resources, and in many cases denial of service to people – often women and girls – who desperately need it.
However, opposition from the “usual suspects”, the international community’s failure to support the ICPD agenda, and the threat of HIV and AIDS are only partial and proximate explanations. I think the ultimate cause is much older and more intractable: prejudice and fear directed at women and especially women’s and girls empowerment in all its forms.
Of course ICPD is only part of the story. Another part – the context that made ICPD possible – is the growing power of the women’s movement and the growing demands for autonomy by individual women, in the family, the economy, the political process, and the courts. ICPD implementation has strengthened women and encouraged them to think in terms of their rights. Rising reports and rising intolerance of GBV both reflect women’s rising presence and rising assertiveness, and men’s perception that they are under threat.
We should pause here a moment and wonder why GBV and opposition to it both seem to be growing in many societies. Women may be more willing to report violence – that’s one possible reason; another may that men see themselves trapped in a zero-sum game. If women’s economic and social power is growing, men’s must be diminishing.
There are a few men who are correct in seeing women’s growing power as a threat to their own. From the village to the nation, from pulpits to parliaments, we find these small groups of men holding on to power, to women’s detriment. It is time for them to recognise that the world has changed; time for them to adapt to new realities or step aside; to move on or move out.
In some places, these men are holding women’s rights hostage to what they call “traditional values”. In effect they are using women to reassure themselves and display to the world that nothing has changed. They claim that the concept of human rights is a foreign import and doesn’t apply to them. Of course this is plain nonsense. The human rights framework as it exists today is universal. It is adequate and applicable to any culture worth the name, even – or perhaps especially – as it regards women.
Let me say it once again: no cultural value worth the name permits or promotes the oppression and enslavement of women. No cultural value permits women to go without education or health care, including sexual and reproductive health. No cultural value permits women’s behaviour to be the standard of cultural expression, while men behave as they please. No cultural value entitles a man to hide behind his sister’s honour, while he attacks other men’s sisters. No cultural value holds women up to veneration as mothers while exposing them to death and disability in childbirth. These are not cultural values or human values – these are the means by which one group of people holds and uses power over another.
I believe that most men can be brought to see that the zero-sum view of women’s empowerment and gender equality is mistaken. I believe that rising expectations for both men and women will dissipate much of men’s unwillingness to make sexual and reproductive health and rights a priority, in the family and the nation. I have no scientific basis for this belief, only long experience and a lot of hope.
It is a matter not just of men’s assumptions but of women’s too. For every woman who asserts herself, there is another who still doesn’t assert or even understand her rights. Many women cannot even yet believe they possess rights, that life is not fore-ordained and can change, and that they themselves can change it. Their passive acceptance only encourages male reaction – so part of the answer must be to educate, advocate and finance wider and deeper implementation of the ICPD consensus, starting with sexual and reproductive health. Stronger commitment is needed from all parties to the consensus, including national governments and the international community.
It is essential that more and more men in leadership positions, in public life and in the home, will take up the fight for sexual and reproductive health and rights as their own. Women and women’s organizations must do their part through education, example and relentless advocacy. The message is “Human rights for women are human rights for everyone.”
I am happy to say that 20 years after ICPD we are on the way to this understanding. The consensus is stronger now than it has ever been. ICPD may have been ahead of its time, but that is only another way of saying that we led the way. The MDGs, the establishment of UNWomen, the resolutions linking sexual and reproductive health and rights with national and global security, all show growing international acceptance of the ICPD approach. Action on the ground, though there is a long way to go, shows that countries and communities understand the significance of the Cairo agenda, and the importance of anchoring policies and programmes firmly on a basis of human rights.
I hope this Conference will be a guidepost for the next 20 years. I hope you will demonstrate your commitment to the work we began in Cairo, and assert your leadership to continue it. The way forward is to recognise, protect and promote human rights in all cultures and all countries, for all human beings, and for women first of all.