reproductive health > features > building on the cairo consensus
Building on the Cairo ConsensusPosted: 28 Sep 2000
by Fred Sai
Fred Sai was Chairman of the Main Committee of the International Conference on Population and Development held in Cairo in 1994 and until recently, Chairman of Ghana's National Population Council. He considers here how far his hopes for ICPD have been realised, and looks especially at its implications for Africa.
An underestimated achievement of the Cairo Conference was the avoidance of major North-South splits. To me, this was largely because the conference preparatory process and the Programme of Action clearly recognised that population as a global problem is not simply one of increasing numbers and therefore mainly a developing country issue. It is intimately woven into sustainable development and environment problems.
It was accepted early on in the preparatory process that overconsumption, extravagant lifestyles and excessive waste production in the wealthier Northern countries contribute to global population and sustainable development problems just as much as rapid population growth in the poorer South - if not more. Of course, tackling these problems is not proving easy - and the political will to do so seems very weak.
However, the main achievement of the Conference to most people was the acceptance that population growth problems cannot be tackled through a macro numbers approach: solutions must be found at the micro level. Programmes must be based on a proper understanding of people and their needs as individuals and communities, on the status of women and must represent a genuine effort to help meet such needs in a caring and sensitive manner. The basis of fertility regulation programmes was to be sexual and reproductive health care.
My main hope at the end of the Cairo Conference was that the far-reaching and radical ICPD recommendations would give added courage to those governments, especially in Africa, who are still unsure about the place of population policies and programmes in overall development, and that they would be ready and willing to support the evolution of such policies as quickly as feasible.
Unfortunately, there has not been a rush to develop population policies as such. I believe though that there has been quite an increase in genuine efforts to try to implement the policies already in place, and to translate agreements which were made through the World Health Organisation, the World Bank and other international organisations to give population and family planning a much higher programme priority.
One bonus is that the reproductive health approach seems to have harmonized the thinking of African leaders themselves about the acceptability of family planning. When I was working in the World Bank one of the problems that was constantly being debated was whether population programmes and projects were going to be acceptable to the Africans: the consensus was that they were acceptable, providing they were presented as a component part of family health or maternal and child health.
Bearing in mind the ruinous maternal mortality rates that persist in most African countries, it is not surprising that African governments have readily accepted the ICPD idea of expanding the programmatic base in terms of total reproductive health, especially as ICPD has woken Africa up to the fact that sexually transmitted diseases, now including the deadly HIV, are controllable and manageable and not something that should be accepted as a normal part of life. STD/HIV awareness creation is a major effort in many countries now.
Pregnant mother with child, Uganda
© Jim Holmes/Axiom
The HIV epidemic has become more serious than the worst forecasts, particularly in Africaa. Fortunately, the majority of African governments now recognise the actual and potential impact of this disease on all aspects of socio-economic development. The international community is also showing increased willingness to help pay for programmes for prevention, management and care. Success stories, though sparse, are beginning to indicate promising directions. Although no vaccine is available yet, there is hope that some useful ones will be available within the decade.
What remains still to be done is to translate this idea into all-embracing reproductive health care programmes which can deal with the whole life cycle of events related to sexuality, human reproduction and therefore safe motherhood, abortion, teenage sexual activity, sexually transmitted disease, and many functional and organic diseases involving the reproductive system. Services to meet these needs cannot all be planned and catered for through the traditional health care delivery system, let alone the usual family planning set up: countries really need to understand that implementation can no longer be done just by a single agency. We need to harmonise the activities of a whole range of governmental and non-governmental agencies to respond better to people's needs.
There is evidence that this is beginning to happen. With UNFPA leadership, the UN agencies are co-operating better among themselves on this issue, they are collaborating better with non-governmental organisations, and the NGOs themselves are starting to form more strategic alliances, and not just working in a vacuum, as many of them traditionally did.
Even more satisfying to me is the fact that there is more co-operation at the field level than at the central national level. At the district level, or the smallest administrative unit of a country, the leaders of agriculture, health and so on know each other and they usually can be brought together to consider a problem in terms of the community. It is when we get to the central national level that difficult problems arise. Ministries, organised departmentally, have set budget lines which cannot easily be used for joint projects with other departments or other ministries. The question of how this problem can be overcome is plaguing many planners.
In this respect we must be realistic and build upon what is already on the ground. Efforts to develop models and approaches are on the way in many countries.
One of the amazing achievements of Cairo was to get a real international consensus on subjects which had previously been considered to be too 'sensitive' for big meetings of this kind: I am particularly thinking of adolescent sexuality, female genital mutilation and unsafe abortion.
There is already some evidence that some governments and organisations are getting more active in opposing unsafe abortion and even reforming archaic laws - although the opposition too is getting more active, because they can never accept that more liberal laws can help save women's lives. I believe that even more important than changing the law is to make the doctors, and health workers generally, understand the true impact of unsafe abortion and to document what is happening. They must also work sympathetically and refuse to be police informers. Associations for the prevention of unsafe abortion are proving helpful in some countries.
More people now realize that it is important to try to remove the criminality and guilt from abortion, so that women who find themselves in difficulties with an unplanned pregnancy can talk to people more freely. Doctors, too, are becoming less judgmental in their approach to unwanted pregnancies.
Post-abortion counselling, which has been neglected in the past, is now being more widely used. This too creates a strategic alliance between the hospital services, the clinical services and the family planning associations.
The other related area where Cairo has certainly been a catalyst for change is in trying to give some visibility and support to emergency contraception. It is in my view one of the contraceptive areas that will be most acceptable to younger people who, because they are generally not in regular sexual unions, find the Pill not very attractive.
In fact, ICPD has given a major impetus to the whole area of adolescent sexual and reproductive health, and to the involvement of young people themselves in programme design and management. Adolescence needs to be viewed not simply in terms of the problems that it raises, but in terms of a real change that has occurred throughout human society, as education and training needs have led to a lengthening of the period of social and psychological development.
This is not simply a developing country problem; in fact in some respects it is an even more serious problem in industrialized countries, and therefore it offers great potential for the interchange of programme approaches and experiences between the industrialized and the developing world. Non-governmental organisations, especially family planning associations, are probably best placed to promote such interchange.
The closer involvement of NGOs was stressed at ICPD - another change of emphasis from previous population conferences - and the Programme of Action calls for a "broad and effective partnership between governments and the non-governmental sector in delivering reproductive health information and services". Traditionally NGOs have played an important role in providing information and services to groups in society not well-served by government programmes, such as the poor, ethnic minorities, adolescents, prostitutes and so on. They have also addressed sensitive issues stressed at ICPD such as abortion, violence against women and female genital mutilation. Already there is evidence that governments are turning to NGOs to help them implement the Programmes of Action which they signed up to in Cairo and Beijing.
NGOs can also help in other areas which ICPD stressed, such as the decentralization of public health programmes to promote community participation in reproductive health care. ICPD rightly called for the commitment and involvement of the people themselves, and an excellent example of making this work in practice is the Africa Agenda undertaken with the support of several multilateral and bilateral agencies. This is an approach whereby research institutions help to find out how communities perceive their population and family planning needs, how they would like to see problems tackled, and the extent to which they would be prepared to be actively involved.
Another area of progress is South-South co-operation. As ICPD underlined, "South-South co-operation at all levels is an important instrument of development" - indeed, one objective was "to increase international financial assistance to direct South-South co-operation and to facilitate financing procedures for direct South-South co-operation". This implies South-South government co-operation, but it does not exclude NGOs. The South-South Partnership Programme sponsored by the Rockefeller Foundation is an example of the potential that exists for such collaboration.
NGOs with an international outreach - like the members of the International Planned Parenthood Federation - are particularly well placed to exchange experience, and well-established family planning associations, like those in India, Thailand, Mexico and Morocco, have already participated, through IPPF, in information exchange through study tours. I believe that South-South co-operation - involving both NGO and governmental alliances - must and will increase, and will play a valuable role in achieving the goals of ICPD - providing that adequate Northern funding is available to facilitate the process.
Unfortunately, this has not materialised. With a few exceptions, there has been no increase in funding levels since 1995, despite the expansion of programmes as demanded in the Program of Action. Especially disappointing has been the failure of the United States to meet the challenge of Cairo largely due to the various contortions of the US Congress, where there has been excessive concern over the issue of abortion. As a result of the failure to provide adequate support for reproductive health services in developing countries, more women have been forced to resort to unsafe abortions than would otherwise have occurred, with devastating consequences for themselves and their families.
But although the outlook for an increase in multilateral funding for the moment remains bleak, some donor countries are beginning to put the monies at the embassy level, and this funding can be tapped by national governments as well as NGOs if they develop good programmes. This is where South to South collaboration comes in. A good number of Southern countries have now got the necessary expertise and can help others to develop good programmes and present these for funding. In my view, that is the way to go.