Development of the Cairo consensus

The outcome of the 1994 International Conference on Population and Development (ICPD) would probably not be possible in the polarised world of today. It produced two key results:
1) Adoption of “Sexual and Reproductive Health and Rights” (SRHR), and
2) Adoption of a Program of Action including funding commitments.

SRHR touch on some of the most sensitive beliefs and traditions and always raise emotions. Since 2001, the world has seen a conservative backlash led and caused by some of the policies of the US Bush administration. One might have expected a reversal of the relatively liberal rights that had been agreed in Cairo – and that had subsequently been further sharpened in progressive direction by the International Conference on Women in Beijing in 1995 and “Cairo+5” in The Hague. Fortunately and perhaps surprisingly, no reversal has taken place.

On the contrary: in Cairo itself, a great number of governments signed with the qualification of some exceptions. However, in 2004, at a UN meeting commemorating 10 years of ICPD, only three countries – including the USA – still made some exceptions. In 2005, at the UN Summit about 5 years into the Millennium Declaration, all UN members, represented at their highest level (including US President Bush) adopted a declaration reconfirming the entire ICPD consensus, and adding “Universal Access to Reproductive Health” as a target to Millennium Development Goal (MDG5). In 2006, the African countries adopted the Maputo Declaration and Plan of Action that contain all the main elements of SRHR.

It should be noted that the first “R” (reproductive) and the “H” (health) of SRHR are least controversial. The “S” raises more resistance: think of pre- or extra-marital sex, and of sexual diversity. The second “R” (rights) meets the same resistance as some other human rights. In this case, some societies are especially afraid of women’s rights (for example: to say “no”, or to contraception, or – worst of all – to safe abortion) and youth rights (for example, to timely and comprehensive sexuality education, access to condoms etc.). But fruitful debate takes place, for example caused by the recent standpoint of Amnesty International on abortion – fiercely attacked by the Vatican. And there is increasing recognition of gay-rights in a number of countries.

The bad news is that in the eyes of human rights and gender activists, the Cairo consensus is not at all very liberal, comprehensive and legally strong. For example, there is no universal right to safe abortion; that is left to each individual country to decide. It is a pity that we should be glad that this consensus remains intact and that further progress seems unlikely in today’s polarised world. Equally worrying is the fact that continuous efforts take place to undermine the Cairo consensus. The actual implementation of the additional target mentioned above, for example, has been actively sabotaged since 2005. Continued vigilance (led by UNFPA) is necessary to translate it into concrete results. And as with all international agreements – many governments pay lip service only, and many societies and even government officials are not aware of what their representatives have underwritten.

On the funding side: international donors agreed in the Cairo Program of Action to fund one-third of the costs of achieving universal access to RH care by 2015. At that time, the donor share was estimated to reach $ 6.1 billion by 2005, or $ 8 billion when adjusted for inflation. In reality, the 22 donor governments have provided only half of this commitment, and that included hugely higher contributions than had been foreseen for the battle against HIV/AIDS. In other words: international funding for all other elements of SRHR, including family planning, has fallen short dramatically. The developing countries themselves, however, have provided more than their anticipated share. This includes their efforts against HIV/AIDS.

In view of the limited space in this article I will single out three areas of SRHR for discussing progress: safe motherhood, family planning, and safe abortion. I do not single out HIV/AIDS that was considered in Cairo as just one of a number of “Sexually Transmittable Diseases” (STD’s) and as such just another element of SRHR, but that since then has got a life of its own, culminating in a separate Millennium Development Goal (MDG 6).

Safe motherhood

This is one of the least controversial areas of SRHR. That makes it all the more shameful that being pregnant and giving birth is still life-threatening in many areas of this world, and that hardly any progress has been made in the last 20 years. The WHO estimates that more than 500,000 women die every year from motherhood complications and a multiple of that number become invalid for the rest of their life. These numbers do not seem to change. Moreover, this burden of disease shows the strongest correlation with poverty among the various disease burdens. A woman in Afghanistan has a chance of 1 in 6 to die in pregnancy or giving birth, compared to 1 in 30,000 in Sweden. The Millennium Development Goal devoted to this problem – MDG 5 – shows the worst progress of all 8 MDG’s and the highest chance of not being achieved by 2015.

This failure is not a matter of technology: there is ample evidence that the availability of basic skilled attendance and some simple medicines – especially to stop haemorrhage (bleeding) – dramatically reduces maternal mortality and morbidity. Good basic health service, especially in rural areas and urban slums, is key for this availability, and that is where the problem lies. The international emphasis on a selected number of poverty-related diseases such as HIV/AIDS – welcome as it is – has also led to an erosion of basic health services because of competition for skilled staff and funding. Fortunately there is a renewed awareness of the importance of basic health services with important actors such as the Global Fund and the Gates Foundation.

For further reading, I recommend volume 370, October 2007, of The Lancet (www.thelancet.com) that is entirely dedicated to maternal health at the occasion of the international “Women Deliver” conference in London in October 2007 (www.womendeliver.org).

Family Planning

Here the world seems to have thrown away the baby with the bathwater. Although family planning constitutes an important element of SRHR as defined in Cairo, it had incurred a bad reputation because of some unethical practices. Moreover, since 1994 “fertility rates” (number of births per woman) had started to drop worldwide, leading to lower population growth. This growth dropped so dramatically in some donor countries that it led to opposite concerns, and in any case to lack of attention for and even hostile attitude towards family planning. International donor funding for family planning has dropped from 55% of assistance for population programmes in 1995 to less than 20% in 2005 or from $ 700 million in 1995 to $ 400 million in 2005.

However, fertility and population growth have remained very high in a number of countries, especially in sub-Sahara Africa and in Central and South Asia. Can you imagine 127 million people in Uganda by 2050? And 305 million in Pakistan? The increased attention for environment and climate change also leads to renewed attention for demographic factors such as population pressure. And recently, some reports have pointed to a strong correlation between fast growing and hence very young populations and the chance to become involved in internal or international conflict. American general (rtd) Claudia Kennedy recently recommended that the “soft power” of family planning might be one element to enhance international security.

Unfortunately, the present US government – still the largest supplier of family planning services and commodities – promotes unrealistic “abstinence only” as prevention method and withholds contraceptive services to unmarried young people. It also continues to boycott UNFPA. On a positive note, the British All Party Parliamentary Group on Population, Development and Reproductive Health has issued a report in January 2007 under the tell-tale title “The Return of the Population Growth Factor”, in which a number of worldwide experts demonstrate the vital importance of demographic factors for the achievement of each of the Millennium Development Goals (see www.appg-popdevrh.org.uk). The UK, Netherlands and some other donors have increased their funding contributions for “Reproductive Health Supplies” (condoms, contraceptives etc.) but much more needs to be done to improve family planning service delivery, especially in “fragile states”.

Safe Abortion

Although statistics are hard to find, it is likely that unsafe abortions remain the single most important cause of women’s mortality and morbidity. The number of (induced) abortions worldwide in 2003 was estimated to be 42 million, 48 percent of which were unsafe, 97 percent of them in developing countries. There is ample evidence that pushing abortion into illegality does not reduce the number of abortions but makes them unsafe. Reversely, legalising abortions does not lead to an increase. My own country – the Netherlands – in which abortion is available upon demand and free of charge, has among the lowest numbers. Nobody likes abortion, and the best answer is adequate prevention of unwanted pregnancies and if the need arises: available and affordable safe service.

In spite of the impression to the contrary because of the loud tone of the abortion debate especially in the USA (between “pro-life” and “pro-choice”) and reversals such as in Nicaragua, there is a worldwide tendency towards liberalising abortion laws: South Africa, Portugal, Mexico, Ethiopia and Ghana are examples. Women worldwide no longer accept to be branded as “baby killers”. Scientific evidence about the human status of the embryo is gaining ground.

The “Cairo” consensus does not call for abortion as a right or for its legalisation. But it does call for the provision of safe abortion services where legal. And, of course, it calls for prevention of unwanted pregnancies. Unfortunately, very few donors dare to support safe abortion services. Civil society must play a key role here. The systematic use of rape as a weapon in some conflict areas should provide an additional humanitarian argument in favour of safe abortion.

Frans Baneke is Executive Director, World Population Foundation, The Netherlands